MEDICARE: JEANETTE LEDOUX LMT 4468

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	4468	NM

General Provider Information

NPI Number	:	1215161401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANETTE LEDOUX LMT 4468

Provider Business Mailing Address
First Line	:	2800 SAN MATEO BLVD NE
Second Line	:	SUITE 106
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-3135
Country	:	US
Telephone Number	:	505-884-9500
Fax Number	:

Provider Business Practice Location Address
First Line	:	2800 SAN MATEO BLVD NE
Second Line	:	SUITE 106
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-3135
Country	:	US
Telephone Number	:	505-884-9500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2009
Last Update Date	:	05/04/2009

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