MEDICARE: MRS. LORI LYNN MOOG

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	171W00000X	Contractor

General Provider Information

NPI Number	:	1780898734
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LORI LYNN MOOG

Provider Business Mailing Address
First Line	:	1258 LEA RANCH DR.
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88012
Country	:	US
Telephone Number	:	505-373-0850
Fax Number	:

Provider Business Practice Location Address
First Line	:	1258 LEA RANCH DR.
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88012
Country	:	US
Telephone Number	:	505-373-0850
Fax Number	:

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

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	07/08/2007

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