Provider Demographics
NPI:1063428431
Name:MIMBRES HEALTH MAINTENANCE ASSOCIATES P C
Entity type:Organization
Organization Name:MIMBRES HEALTH MAINTENANCE ASSOCIATES P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAFON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-544-2800
Mailing Address - Street 1:850 W. FLORIDA
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030
Mailing Address - Country:US
Mailing Address - Phone:505-544-2800
Mailing Address - Fax:505-544-2801
Practice Address - Street 1:850 W FLORIDA ST
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-4558
Practice Address - Country:US
Practice Address - Phone:505-544-2800
Practice Address - Fax:505-544-2801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2003-06342080N0001X
NM81-71207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM26393Medicaid
NM47426781Medicaid
NM48702Medicaid
NM2134853Medicare ID - Type UnspecifiedDR. LAFON
NM48702Medicaid