Basic Information
| Provider Information | |||||||||
| NPI: | 1417472192 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FNCH OUTPATIENT SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FNCH OUTPATIENT SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5608 ZUNI RD SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871082926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052622481 | ||||||||
| FaxNumber: | 5052657045 | ||||||||
| Practice Location | |||||||||
| Address1: | 634 MANZANO STREET NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052622481 | ||||||||
| FaxNumber: | 5052657045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2017 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | GUTIERREZ | ||||||||
| AuthorizedOfficialFirstName: | SUZETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5052626567 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FIRST NATIONS COMMUNITY HEALTH SOURCE, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 0004-6912 | 05 | NM | MEDICAID |