1366783458 NPI number — SW LIPOSCULPTURE & COSMETIC LASER

Table of content: (NPI 1366783458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366783458 NPI number — SW LIPOSCULPTURE & COSMETIC LASER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SW LIPOSCULPTURE & COSMETIC LASER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366783458
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3850 FOOTHILLS RD
Provider Second Line Business Mailing Address:
SUITE 9
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88011-4632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-532-1657
Provider Business Mailing Address Fax Number:
575-532-1665

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3850 FOOTHILLS RD
Provider Second Line Business Practice Location Address:
SUITE 9
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88011-4632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-532-1657
Provider Business Practice Location Address Fax Number:
575-532-1665
Provider Enumeration Date:
03/14/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
REYNAUD
Authorized Official First Name:
MARIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/OFFICE MANAGER
Authorized Official Telephone Number:
575-532-1657

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  99-226 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RP1001X , with the licence number: 99-226 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)