=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598097123
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GAIL DENISE MELPOLDER COMS, CLVT, CRC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2010
-----------------------------------------------------
Last Update Date | 02/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6 FAWN LN
-----------------------------------------------------
City | LA LUZ
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88337-9339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-415-2008
-----------------------------------------------------
Fax | 888-453-1138
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 FAWN LN
-----------------------------------------------------
City | LA LUZ
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88337-9339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-415-2008
-----------------------------------------------------
Fax | 888-453-1138
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 4815 - ACVREP
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 5622 ACVREP
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 00016215 CRCC
-----------------------------------------------------
License Number State |
-----------------------------------------------------