MEDICARE: THERESA VEGA

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	224Z00000X	Occupational Therapy Assistant	3198	NM

General Provider Information

NPI Number	:	1457763856
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA VEGA

Provider Business Mailing Address
First Line	:	301 PERKINS DR STE C
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-3248
Country	:	US
Telephone Number	:	575-523-7243
Fax Number	:

Provider Business Practice Location Address
First Line	:	1080 MED PARK DR
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-3226
Country	:	US
Telephone Number	:	575-523-7243
Fax Number	:

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

Provider Enumeration Date	:	05/20/2014
Last Update Date	:	05/20/2014

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Directions to “ THERESA VEGA ” Practice Location

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