Healthcare Provider Details

I. General information

NPI: 1487668323
Provider Name (Legal Business Name): OLIVIA SERNA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 05/06/2021
Certification Date: 05/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 EL PASEO RD. SUITE B
LAS CRUCES NM
88001
US

IV. Provider business mailing address

2500 EL PASEO RD. SUITE B
LAS CRUCES NM
88001
US

V. Phone/Fax

Practice location:
  • Phone: 575-541-4409
  • Fax: 575-541-4452
Mailing address:
  • Phone: 575-541-4409
  • Fax: 575-541-4452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number11639
License Number StateNM

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier61677035
Identifier TypeMEDICAID
Identifier StateNM
Identifier Issuer
# 2
IdentifierNM00TB93
Identifier TypeOTHER
Identifier StateNM
Identifier IssuerBLUE CROSS BLUE SHIELD OF NEW MEXICO

VIII. Authorized Official

Name: OLIVIA SERNA
Title or Position: OWNER
Credential:
Phone: 505-541-4409