Provider Demographics
NPI:1831367481
Name:LAIDLEY, KEMP BRUCE
Entity type:Individual
Prefix:
First Name:KEMP
Middle Name:BRUCE
Last Name:LAIDLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3937 SPRING BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-9624
Mailing Address - Country:US
Mailing Address - Phone:575-706-4455
Mailing Address - Fax:
Practice Address - Street 1:2319 W PIERCE ST STE A
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3515
Practice Address - Country:US
Practice Address - Phone:505-706-4455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-18
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3357225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist