Basic Information
| Provider Information | |||||||||
| NPI: | 1750653069 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOLINA HEALTHCARE OF NEW MEXICO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 OCEANGATE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624996191 | ||||||||
| FaxNumber: | 5624996171 | ||||||||
| Practice Location | |||||||||
| Address1: | 7317 CENTRAL NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871082015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055531630 | ||||||||
| FaxNumber: | 5624996171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2012 | ||||||||
| LastUpdateDate: | 02/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | PADRON | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | AFC, WESTERN REGIONAL DIRECTOR CLIN | ||||||||
| AuthorizedOfficialTelephone: | 5624996191 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.