Healthcare Provider Details

I. General information

NPI: 1013050012
Provider Name (Legal Business Name): MICHAEL J O'LAREY ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC 3FAC NEW MEXICO STATE UNIVERSITY P P BOX 30001
LAS CRUCES NM
88003-8001
US

IV. Provider business mailing address

3823 LAMANITE CT
LAS CRUCES NM
88012-7919
US

V. Phone/Fax

Practice location:
  • Phone: 505-646-1526
  • Fax: 505-646-3435
Mailing address:
  • Phone: 505-646-1526
  • Fax: 505-646-3435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number53
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: