Basic Information
| Provider Information | |||||||||
| NPI: | 1497280143 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANDIA MOUNTAIN MEDICAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEW MEXICO MEDICAL URGENT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12127B HWY 14 N STE 5 | ||||||||
| Address2: | |||||||||
| City: | CEDAR CREST | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052815180 | ||||||||
| FaxNumber: | 5052815320 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 QUAIL TRL UNIT B | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870157185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052815180 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2017 | ||||||||
| LastUpdateDate: | 05/12/2017 | ||||||||
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| AuthorizedOfficialLastName: | BEVERLY | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | MARC | ||||||||
| AuthorizedOfficialTitleorPosition: | COO/ OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5052815180 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SANDIA MOUNTAIN MEDICAL, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 02478 | NM | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.