Provider Demographics
NPI:1295011740
Name:FLORES, LETICIA MICHELLE
Entity Type:Individual
Prefix:MS
First Name:LETICIA
Middle Name:MICHELLE
Last Name:FLORES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W GRIGGS AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1234
Mailing Address - Country:US
Mailing Address - Phone:575-647-2800
Mailing Address - Fax:575-647-2898
Practice Address - Street 1:1400 SUDDERTH DRIVE
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345
Practice Address - Country:US
Practice Address - Phone:575-630-0571
Practice Address - Fax:575-630-0574
Is Sole Proprietor?:No
Enumeration Date:2011-10-28
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18677037Medicaid