Healthcare Provider Details

I. General information

NPI: 1487610689
Provider Name (Legal Business Name): CARLOS DAVID MIERA LISC INDEPENDENT SOC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 SIPAPU RD
TAOS NM
87571
US

IV. Provider business mailing address

PO BOX 714
ARROYO SECO NM
87514
US

V. Phone/Fax

Practice location:
  • Phone: 505-758-5857
  • Fax: 505-758-2832
Mailing address:
  • Phone: 505-776-8915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: