Healthcare Provider Details

I. General information

NPI: 1013415637
Provider Name (Legal Business Name): MELANIE J LUCERO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 PARK ST
SOCORRO NM
87801-4543
US

IV. Provider business mailing address

128 STALLION CIR
SOCORRO NM
87801-4454
US

V. Phone/Fax

Practice location:
  • Phone: 575-838-7614
  • Fax: 575-838-0508
Mailing address:
  • Phone: 575-418-1094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: