Healthcare Provider Details

I. General information

NPI: 1225069230
Provider Name (Legal Business Name): TAOS SPORTS MEDICINE SRVS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1398 WEIMER RD STE 203
TAOS NM
87571
US

IV. Provider business mailing address

1398 WEIMER RD ST 203
TAOS NM
87571
US

V. Phone/Fax

Practice location:
  • Phone: 505-737-0304
  • Fax: 505-737-0383
Mailing address:
  • Phone: 505-737-0304
  • Fax: 505-737-0383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberNM3072
License Number StateNM

VIII. Authorized Official

Name: JOCELYN LUCERO
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-737-0304