Provider Demographics
NPI:1376866947
Name:LAS CRUCES PHYSICIAN PRACTICES, LLC
Entity type:Organization
Organization Name:LAS CRUCES PHYSICIAN PRACTICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-521-5277
Mailing Address - Street 1:PO BOX 6310
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88006-6310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2530 S TELSHOR BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4907
Practice Address - Country:US
Practice Address - Phone:575-521-5277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM900522525Medicare PIN