Basic Information
| Provider Information | |||||||||
| NPI: | 1588947485 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OPTUMCARE NEW MEXICO, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DAVITA MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26028 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052627960 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5150 JOURNAL CENTER BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871095900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052623370 | ||||||||
| FaxNumber: | 5052623226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2011 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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| AuthorizedOfficialLastName: | LIETHEN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 9522056262 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
No ID Information.