MEDICARE: MRS. VIRGINIA NICHOLLS ALDEA OTR/L

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	225X00000X	Occupational Therapist	2427	NM
2	225X00000X	Occupational Therapist	111412	TX

General Provider Information

NPI Number	:	1912142316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VIRGINIA NICHOLLS ALDEA OTR/L

Provider Business Mailing Address
First Line	:	3308 GILA CT
Second Line	:
City	:	DEMING
State	:	NM
Zip	:	88030-8673
Country	:	US
Telephone Number	:	575-545-1913
Fax Number	:	575-546-0061

Provider Business Practice Location Address
First Line	:	111 N PEARL ST
Second Line	:
City	:	DEMING
State	:	NM
Zip	:	88030-3835
Country	:	US
Telephone Number	:	575-544-4663
Fax Number	:	575-544-4665

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

Provider Enumeration Date	:	12/14/2008
Last Update Date	:	12/14/2008

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