Healthcare Provider Details

I. General information

NPI: 1891070777
Provider Name (Legal Business Name): TAOS PROFESSIONAL SERVICES,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2011
Last Update Date: 06/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1397 WEIMER RD
TAOS NM
87571-6253
US

IV. Provider business mailing address

1397 WEIMER RD
TAOS NM
87571-6253
US

V. Phone/Fax

Practice location:
  • Phone: 575-751-5746
  • Fax: 575-751-7661
Mailing address:
  • Phone: 575-758-8883
  • Fax: 575-751-7661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: SUSAN DYMOND
Title or Position: MNGR
Credential:
Phone: 575-751-5746