Provider Demographics
NPI:1104366533
Name:LA LUZ THERAPY SERVICES
Entity Type:Organization
Organization Name:LA LUZ THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:RODDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-363-9582
Mailing Address - Street 1:1312 MESA WOOD PL NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-6565
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5400 SEVILLA AVE NW STE E
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-1853
Practice Address - Country:US
Practice Address - Phone:505-363-9582
Practice Address - Fax:505-214-5137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-04
Last Update Date:2019-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4197261QP2000X
NM4196261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1972853026OtherNPI
NM1730501883OtherNPI