Healthcare Provider Details

I. General information

NPI: 1669828687
Provider Name (Legal Business Name): DEBRA WILCOX LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2016
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 MECHEM DR STE 5
RUIDOSO NM
88345-7060
US

IV. Provider business mailing address

1009 MECHEM DR STE 5
RUIDOSO NM
88345-7060
US

V. Phone/Fax

Practice location:
  • Phone: 575-802-3791
  • Fax:
Mailing address:
  • Phone: 575-802-3791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number8242
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number8242
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: