Basic Information
| Provider Information | |||||||||
| NPI: | 1083197032 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAVITA MEDICAL GROUP NEW MEXICO, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26028 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052623135 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5150 JOURNAL CENTER BLVD NE FL 2 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871095900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052321530 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2018 | ||||||||
| LastUpdateDate: | 09/14/2018 | ||||||||
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| AuthorizedOfficialLastName: | KOTTE | ||||||||
| AuthorizedOfficialFirstName: | VIJAY | ||||||||
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| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 3038766457 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DAVITA MEDICAL GROUP NEW MEXICO, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.