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909 N Date St Suite B T Or C NM 87901-1747 | |
(575) 636-2388 | |
(575) 680-2591 |
Full Name | |
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Speciality | Family Medicine |
Location | 909 N Date St, T Or C, New Mexico |
Authorized Official Name and Position | Chandran Vedamanikam (MEDICAL DIRECTOR) |
Authorized Official Contact | 5756362388 |
Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
Mailing Address | Practice Location Address |
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Po Box 2707 Las Cruces NM 88004-2707 Ph: (575) 526-3625 | 909 N Date St Suite B T Or C NM 87901-1747 Ph: (575) 636-2388 |
NPI Number | 1851660229 |
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Provider Enumeration Date | 12/14/2011 |
Last Update Date | 09/23/2017 |
Identifier | Type | State | Issuer |
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1851660229 | NPI | - | NPPES |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
207Q00000X | Family Medicine | MD2011-0121 (New Mexico) | Primary |
261Q00000X | Clinic/center | MD2011-0121 (New Mexico) | Secondary |