Provider Demographics
NPI:1528276318
Name:ALBUQUERQUE ORTHOTICS & PROSTHETICS
Entity type:Organization
Organization Name:ALBUQUERQUE ORTHOTICS & PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROSTHETIST ORTHOTIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:URSO
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:505-342-0333
Mailing Address - Street 1:PO BOX 90445
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87199-0445
Mailing Address - Country:US
Mailing Address - Phone:505-342-0333
Mailing Address - Fax:505-342-0336
Practice Address - Street 1:4909 ELLISON ST NE
Practice Address - Street 2:SUITE A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4331
Practice Address - Country:US
Practice Address - Phone:505-342-0333
Practice Address - Fax:505-342-0336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMFA0048723335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNMOOTA31OtherBLUECROSS BLUESHIELD NM
AZ957699Medicaid
NM33680825Medicaid
KY=========OtherUNITED HEALTHCARE
AZ957699Medicaid
NM=========OtherSMWIA LOCAL 49
NM=========OtherLOVELACE HEALTH PLAN
NM=========OtherHEALTHSOUTH REHAB
NM=========OtherCCMSI OF NM
NM33680825Medicaid
CT=========OtherCIGNA HEALTHCARE
AZ=========OtherSOUTHWEST SERVICE ADM-ALB
NM=========Medicaid
CT=========OtherCIGNA HEALTHCARE
NM=========Medicaid
NM33680825Medicaid