MEDICARE: SW LIPOSCULPTURE & COSMETIC LASER

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	207RP1001X	Pulmonary Disease Physician	99-226	NM
2	207R00000X	Internal Medicine Physician	99-226	NM

General Provider Information

NPI Number	:	1366783458
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SW LIPOSCULPTURE & COSMETIC LASER

Provider Business Mailing Address
First Line	:	3850 FOOTHILLS RD
Second Line	:	SUITE 9
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-4632
Country	:	US
Telephone Number	:	575-532-1657
Fax Number	:	575-532-1665

Provider Business Practice Location Address
First Line	:	3850 FOOTHILLS RD
Second Line	:	SUITE 9
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-4632
Country	:	US
Telephone Number	:	575-532-1657
Fax Number	:	575-532-1665

Authorized Official
Title or Position	:	OWNER/OFFICE MANAGER
Name	:	MARIE REYNAUD
Credential	:
Telephone Number	:	575-532-1657

Provider Enumeration Date	:	03/14/2013
Last Update Date	:	03/14/2013

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