Healthcare Provider Details

I. General information

NPI: 1366783458
Provider Name (Legal Business Name): SW LIPOSCULPTURE & COSMETIC LASER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2013
Last Update Date: 03/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 FOOTHILLS RD SUITE 9
LAS CRUCES NM
88011-4632
US

IV. Provider business mailing address

3850 FOOTHILLS RD SUITE 9
LAS CRUCES NM
88011-4632
US

V. Phone/Fax

Practice location:
  • Phone: 575-532-1657
  • Fax: 575-532-1665
Mailing address:
  • Phone: 575-532-1657
  • Fax: 575-532-1665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number99-226
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number99-226
License Number StateNM

VIII. Authorized Official

Name: MARIE REYNAUD
Title or Position: OWNER/OFFICE MANAGER
Credential:
Phone: 575-532-1657