Provider Demographics
NPI:1730262783
Name:ALONZO, THERESA MARY (RT LAB TECH)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARY
Last Name:ALONZO
Suffix:
Gender:F
Credentials:RT LAB TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:12000 STONE LAKE ROAD
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528-0187
Mailing Address - Country:US
Mailing Address - Phone:505-759-3291
Mailing Address - Fax:505-759-3532
Practice Address - Street 1:12000 STONE LAKE ROAD
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528-0187
Practice Address - Country:US
Practice Address - Phone:505-759-3291
Practice Address - Fax:505-759-3532
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2022-07-21
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2008-06-16
Provider Licenses
StateLicense IDTaxonomies
NM291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000K3526Medicaid
NMHSZ196OtherMEDICARE PART B
NM320057Medicare Oscar/Certification