=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679897003
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARL SALAZAR LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2010
-----------------------------------------------------
Last Update Date | 03/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8625 GOLF COURSE RD NW STE A-2
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87114-5114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-899-6600
-----------------------------------------------------
Fax | 505-899-3262
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 219 ARVADA AVE NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87102-1101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-843-9021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | LMT3654
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 3654
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------