Healthcare Provider Details

I. General information

NPI: 1235424177
Provider Name (Legal Business Name): RELIANT PROSTHETICS SOUTHWEST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2011
Last Update Date: 09/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 COUNTRY CLUB RD SUITE B
SANTA TERESA NM
88008-9449
US

IV. Provider business mailing address

1300 COUNTRY CLUB RD SUITE B
SANTA TERESA NM
88008-9449
US

V. Phone/Fax

Practice location:
  • Phone: 575-589-3200
  • Fax: 575-589-3201
Mailing address:
  • Phone: 575-589-3200
  • Fax: 575-589-3201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. TOM L LOPOSER JR.
Title or Position: PARTNER
Credential:
Phone: 972-470-0300