Provider Demographics
NPI:1225069230
Name:TAOS SPORTS MEDICINE SRVS LLC
Entity Type:Organization
Organization Name:TAOS SPORTS MEDICINE SRVS LLC
Other - Org Name:TAOS MRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOCELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-737-0304
Mailing Address - Street 1:1398 WEIMER RD
Mailing Address - Street 2:ST 203
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571
Mailing Address - Country:US
Mailing Address - Phone:505-737-0304
Mailing Address - Fax:505-737-0383
Practice Address - Street 1:1398 WEIMER RD
Practice Address - Street 2:STE 203
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:505-737-0304
Practice Address - Fax:505-737-0383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208100000X
NMNM30722085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPRCVA41646OtherMALINE SALUD
NM65377273Medicaid