Basic Information
| Provider Information | |||||||||
| NPI: | 1649782962 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOLINA HEALTHCARE OF NEW MEXICO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 OCEANGATE STE 100 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885625442 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 TIJERAS AVE NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871023234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885625441 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2017 | ||||||||
| LastUpdateDate: | 10/26/2017 | ||||||||
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| AuthorizedOfficialLastName: | SORRELLS | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PLAN PRESIDENT-MHNM | ||||||||
| AuthorizedOfficialTelephone: | 8885625442 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MOLINA HEALTHCARE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.