Provider Demographics
NPI:1659689347
Name:TAOS SPORTS MEDICINE SERICES LLC
Entity Type:Organization
Organization Name:TAOS SPORTS MEDICINE SERICES LLC
Other - Org Name:ANGEL FIRE PHYSICAL THERAPY
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:575-737-0304
Mailing Address - Street 1:1398 WEIMER RD
Mailing Address - Street 2:STE 203
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6397
Mailing Address - Country:US
Mailing Address - Phone:575-737-0304
Mailing Address - Fax:575-737-0383
Practice Address - Street 1:12 CRESTVIEW DRIVE
Practice Address - Street 2:STE 1S
Practice Address - City:ANGEL FIRE
Practice Address - State:NM
Practice Address - Zip Code:87710-0489
Practice Address - Country:US
Practice Address - Phone:575-377-1900
Practice Address - Fax:575-377-2383
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TAOS SPORTS MEDICINE SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3072B12251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM43383386Medicaid
NM700521047OtherMEDICARE GROUP PTAN