Provider Demographics
NPI:1285093617
Name:SLADE, LORRAINE MARGARET (LMT)
Entity type:Individual
Prefix:
First Name:LORRAINE
Middle Name:MARGARET
Last Name:SLADE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 BOREALIS AVE SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-2877
Mailing Address - Country:US
Mailing Address - Phone:505-205-2291
Mailing Address - Fax:
Practice Address - Street 1:1615 BOREALIS AVE SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-2877
Practice Address - Country:US
Practice Address - Phone:505-205-2291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-12
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLMT #6906172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist