Provider Demographics
NPI:1538176052
Name:DEBORD, ILDA (LMT)
Entity type:Individual
Prefix:
First Name:ILDA
Middle Name:
Last Name:DEBORD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:ABOUT
Other - Middle Name:YOU
Other - Last Name:MASSAGES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LLC
Mailing Address - Street 1:6352 FLOR DE MAYO PL NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-2114
Mailing Address - Country:US
Mailing Address - Phone:505-514-7110
Mailing Address - Fax:505-898-9748
Practice Address - Street 1:6352 FLOR DE MAYO PL NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-2114
Practice Address - Country:US
Practice Address - Phone:505-514-7110
Practice Address - Fax:505-898-9748
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2009-07-22
Deactivation Date:2008-09-05
Deactivation Code:
Reactivation Date:2009-07-22
Provider Licenses
StateLicense IDTaxonomies
NM4079174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMOORE78OtherBXBS