Provider Demographics
NPI:1144578410
Name:LODERUS, CARMEN L (LMT)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:L
Last Name:LODERUS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 VASSAR DR SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2967
Mailing Address - Country:US
Mailing Address - Phone:505-232-2460
Mailing Address - Fax:
Practice Address - Street 1:1212 VASSAR DR SE
Practice Address - Street 2:SUITE A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2967
Practice Address - Country:US
Practice Address - Phone:505-232-2460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5038225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist