Healthcare Provider Details

I. General information

NPI: 1821167636
Provider Name (Legal Business Name): ANTHONY JOHN FLORES ASL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 09/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

I-40 WEST, EXIT 114 BUILDING #1125
LAGUNA NM
87026-4611
US

IV. Provider business mailing address

3520 STETSON ST SW
LOS LUNAS NM
87031-6382
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-6008
  • Fax: 505-552-6398
Mailing address:
  • Phone: 505-259-8550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number4283
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: