Provider Demographics
NPI:1396803953
Name:LANGE, LORI BIERI (MOT)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:BIERI
Last Name:LANGE
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 GUADALUPE TRL NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-3300
Mailing Address - Country:US
Mailing Address - Phone:505-345-4237
Mailing Address - Fax:
Practice Address - Street 1:230 TRUMAN ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1333
Practice Address - Country:US
Practice Address - Phone:505-268-9506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM437174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMG5602Medicaid