Provider Demographics
NPI:1235226614
Name:SOUTHEAST NEW MEXICO PODIATRY ASSOCIATES INC
Entity Type:Organization
Organization Name:SOUTHEAST NEW MEXICO PODIATRY ASSOCIATES INC
Other - Org Name:SOUTHEAST NEW MEXICO PODIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LYLE
Authorized Official - Middle Name:REY
Authorized Official - Last Name:FOLSOM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:575-885-3445
Mailing Address - Street 1:1016 W PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-4013
Mailing Address - Country:US
Mailing Address - Phone:575-885-3445
Mailing Address - Fax:575-887-0163
Practice Address - Street 1:1016 W PIERCE ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-4013
Practice Address - Country:US
Practice Address - Phone:575-885-3445
Practice Address - Fax:575-887-0163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM89008863Medicaid
NMDA5243OtherRR MEDICARE
NM5083500001Medicare NSC
NM400521141Medicare PIN