Basic Information
| Provider Information | |||||||||
| NPI: | 1689881245 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HIDALGO MEDICAL SERVICES | ||||||||
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| OtherOrganizationName: | HMS LORDSBURG HIGH SCHOOL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 DE MOSS ST | ||||||||
| Address2: | |||||||||
| City: | LORDSBURG | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880452618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755422368 | ||||||||
| FaxNumber: | 5755422388 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LORDSBURG | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880451643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755423389 | ||||||||
| FaxNumber: | 5755422388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2007 | ||||||||
| LastUpdateDate: | 03/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | OTERO | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5755422322 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HIDALGO MEDICAL SERVICES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1000X | 7678 | NM | N | Ambulatory Health Care Facilities | Clinic/Center | Student Health | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 78001064 | 05 | NM | MEDICAID |