MEDICARE: TAMMY R LUCERO

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	373H00000X	Day Training/Habilitation Specialist

General Provider Information

NPI Number	:	1730659285
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMMY R LUCERO

Provider Business Mailing Address
First Line	:	PO BOX 4258
Second Line	:
City	:	FAIRVIEW
State	:	NM
Zip	:	87533-4258
Country	:	US
Telephone Number	:	505-699-5814
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501 E FAIRVIEW LN
Second Line	:
City	:	ESPANOLA
State	:	NM
Zip	:	87532-2846
Country	:	US
Telephone Number	:	505-699-5814
Fax Number	:

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

Provider Enumeration Date	:	11/27/2018
Last Update Date	:	11/27/2018

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Directions to “ TAMMY R LUCERO ” Practice Location

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