Healthcare Provider Details

I. General information

NPI: 1922413376
Provider Name (Legal Business Name): LOW VISION REHABILITATION IN NEW MEXICO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 06/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 E BUENA VISTA ST APT 5
SANTA FE NM
87505-2675
US

IV. Provider business mailing address

303 E BUENA VISTA ST APT 5
SANTA FE NM
87505-2675
US

V. Phone/Fax

Practice location:
  • Phone: 505-259-3672
  • Fax:
Mailing address:
  • Phone: 505-259-3672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number3146
License Number StateNM

VIII. Authorized Official

Name: COBY L LIVINGSTONE
Title or Position: OCCUPATIONAL THERAPIST
Credential:
Phone: 505-259-3672