Individual
TEDDEY PROVENCIO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
118 S MAIN ST, LAS CRUCES, NM 88001
(575) 527-7975
(575) 647-2898
Mailing address
100 W GRIGGS AVE, LAS CRUCES, NM 88001-1234
(575) 647-2800
(575) 647-2898
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
47043
—
NM
Enumeration date
11/30/2010
Last updated
11/30/2010
About Stedi
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