Basic Information
| Provider Information | |||||||||
| NPI: | 1700871993 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LCT INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 62002 NBU20 | ||||||||
| Address2: | |||||||||
| City: | ESPANOLA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875322711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057478639 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1010 SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | ESPANOLA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875323456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057537111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | CARMEN | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5057478639 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | NM | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | NM006426 | 01 | NM | BCBS NM GROUP | OTHER | 17104505 | 05 | NM | MEDICAID | 430074229 | 01 | NM | RAILROAD MEDICARE | OTHER | NM026426 | 01 | NM | NM BCBS | OTHER |