Basic Information
Provider Information | |||||||||
NPI: | 1063147270 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NM INTEGRATED SOLUTION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2523 | ||||||||
Address2: |   | ||||||||
City: | SUNLAND PARK | ||||||||
State: | NM | ||||||||
PostalCode: | 880632523 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2801 MISSOURI AVE | ||||||||
Address2: |   | ||||||||
City: | LAS CRUCES | ||||||||
State: | NM | ||||||||
PostalCode: | 880115075 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5759151338 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/21/2022 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TORRES | ||||||||
AuthorizedOfficialFirstName: | SANTIAGO | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5759151338 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | III | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Community Health Worker |   | 174200000X |   |   | N |   | Other Service Providers | Meals |   | 175T00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP |   |   |   | 261QM1300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QP2300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.