Healthcare Provider Details

I. General information

NPI: 1386694636
Provider Name (Legal Business Name): RENEE D LAVADIE CASE MANAGER
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 SIPAPU ROAD
TAOS NM
87571
US

IV. Provider business mailing address

PO BOX 366
EL PRADO NM
87529
US

V. Phone/Fax

Practice location:
  • Phone: 505-758-5857
  • Fax: 505-758-2832
Mailing address:
  • Phone: 505-776-4232
  • Fax: 505-776-4232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: