Provider Demographics
NPI:1871802082
Name:NEW MEXICO PHS LLC
Entity type:Organization
Organization Name:NEW MEXICO PHS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-261-4858
Mailing Address - Street 1:6565 AMERICAS PKWY NE STE 200
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-8172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9155 CRESTWYN HILLS DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-8501
Practice Address - Country:US
Practice Address - Phone:901-261-4848
Practice Address - Fax:901-261-4849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty