Organization
TAOS SPORTS MEDICINE SERICES LLC
Active
Parent organization
TAOS SPORTS MEDICINE SERVICES, LLC
Other names
Angel Fire Physical Therapy
Organization subpart
Yes
Provider details
NPI number
Legal business name
TAOS SPORTS MEDICINE SERVICES, LLC
Authorized official
JOCELYN LUCERO (OFFICE MANAGER)
(575) 737-0304
Entity
Organization
Contact information
Practice address
12 CRESTVIEW DRIVE, STE 1S, ANGEL FIRE, NM 87710-0489
(575) 377-1900
(575) 377-2383
Mailing address
1398 WEIMER RD, STE 203, TAOS, NM 87571-6397
(575) 737-0304
(575) 737-0383
Taxonomy
Speciality
Code
Description
License number
State
2251X0800X
Orthopedic Physical Therapist
Primary
3072B1
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
43383386
—
NM
01
—
700521047
MEDICARE GROUP PTAN
NM
Enumeration date
09/16/2010
Last updated
09/16/2010
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