=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962671263
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURGICAL PARTNERS OF LAS CRUCES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2008
-----------------------------------------------------
Last Update Date | 11/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1205 S TELSHOR BLVD
-----------------------------------------------------
City | LAS CRUCES
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88011-4748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-522-6144
-----------------------------------------------------
Fax | 575-522-6171
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1205 S TELSHOR BLVD
-----------------------------------------------------
City | LAS CRUCES
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88011-4748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-522-6144
-----------------------------------------------------
Fax | 575-522-6171
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. DELILAH PRIETO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 575-522-6144
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 3332
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------