MEDICARE: HOLLY BECK IBCLC

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	174N00000X	Lactation Consultant (Non-RN)	55895	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	55895	OTHER	NM	LICENSE

General Provider Information

NPI Number	:	1386205672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY BECK IBCLC

Provider Business Mailing Address
First Line	:	924 RIO VISTA ST
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87501-1552
Country	:	US
Telephone Number	:	505-795-6404
Fax Number	:

Provider Business Practice Location Address
First Line	:	924 RIO VISTA ST
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87501-1552
Country	:	US
Telephone Number	:	505-795-6404
Fax Number	:

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

Provider Enumeration Date	:	06/26/2019
Last Update Date	:	06/26/2019

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