1043407778 NPI number — MRS. ROBERTA ALBINA LUCERO MPT ATC

Table of content: MRS. ROBERTA ALBINA LUCERO MPT ATC (NPI 1043407778)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043407778 NPI number — MRS. ROBERTA ALBINA LUCERO MPT ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUCERO
Provider First Name:
ROBERTA
Provider Middle Name:
ALBINA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MPT ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROYBAL
Provider Other First Name:
ROBERTA
Provider Other Middle Name:
ALBINA
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
ATC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1043407778
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
624 UNIVERSITY AVE
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87701-4252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-472-8946
Provider Business Mailing Address Fax Number:
575-472-8948

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
624 UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87701-4252
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-454-1078
Provider Business Practice Location Address Fax Number:
505-454-1164
Provider Enumeration Date:
09/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  3441 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 81308264 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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