Provider Demographics
NPI:1679297139
Name:PADILLA, LORI R (CNCT)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:R
Last Name:PADILLA
Suffix:
Gender:F
Credentials:CNCT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 YUCCA DR
Mailing Address - Street 2:
Mailing Address - City:LA LUZ
Mailing Address - State:NM
Mailing Address - Zip Code:88337-9549
Mailing Address - Country:US
Mailing Address - Phone:575-491-0479
Mailing Address - Fax:
Practice Address - Street 1:2050 SCENIC DR
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-3880
Practice Address - Country:US
Practice Address - Phone:575-434-0901
Practice Address - Fax:575-437-1992
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM520204R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
520OtherAMERICAN BOARD OF ELECTRODIAGNOSTIC MEDICINE