Basic Information
| Provider Information | |||||||||
| NPI: | 1487741674 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THI OF NEW MEXICO AT ALBUQUERQUE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPECIALTY HOSPITAL OF ALBUQUERQUE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 930 RIDGEBROOK RD | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211529390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107731000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 235 ELM ST NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871023672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058425550 | ||||||||
| FaxNumber: | 5057676460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2006 | ||||||||
| LastUpdateDate: | 03/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | HUERTA | ||||||||
| AuthorizedOfficialFirstName: | JOSE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5058425550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X | Y | Hospitals | Long Term Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 19882513 | 05 | NM | MEDICAID |