Healthcare Provider Details

I. General information

NPI: 1255818530
Provider Name (Legal Business Name): LAGO CLARO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2018
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 S. ESPINA ST
LAS CRUCES NM
88001
US

IV. Provider business mailing address

1925 ANITA DR
LAS CRUCES NM
88001-2027
US

V. Phone/Fax

Practice location:
  • Phone: 575-642-0650
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: ANN M SKIRVIN
Title or Position: BILLER/CREDENTIALER
Credential:
Phone: 915-345-5489