Basic Information
| Provider Information | |||||||||
| NPI: | 1639145808 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALBUQUERQUE CENTER FOR RHEUMATOLOGY PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ALBUQUERQUE REHABILITATION & RHEUMATOLOGY PC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1617 UNIVERSITY BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871021710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053414148 | ||||||||
| FaxNumber: | 5053459914 | ||||||||
| Practice Location | |||||||||
| Address1: | 1617 UNIVERSITY BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871021710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053414148 | ||||||||
| FaxNumber: | 5053459914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 02/28/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PACHECO | ||||||||
| AuthorizedOfficialFirstName: | LEROY | ||||||||
| AuthorizedOfficialMiddleName: | ARNOLD | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5053414148 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 94-116 | NM | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 12375 | 05 | NM | MEDICAID | 522944752M | 01 | MEDICARE | OTHER |