MEDICARE: MR. MAHONRI A TELLES L.M.T

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	225700000X	Massage Therapist	8433	NM

General Provider Information

NPI Number	:	1376099531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MAHONRI A TELLES L.M.T

Provider Business Mailing Address
First Line	:	4784 SAROMI LN
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-6806
Country	:	US
Telephone Number	:	575-640-0843
Fax Number	:	575-680-2225

Provider Business Practice Location Address
First Line	:	4784 SAROMI LN
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-6806
Country	:	US
Telephone Number	:	575-640-0843
Fax Number	:	575-680-2225

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

Provider Enumeration Date	:	08/28/2016
Last Update Date	:	08/28/2016

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