Provider Demographics
NPI:1902333776
Name:PLACITAS MOUNTAIN MEDICAL, INC
Entity type:Organization
Organization Name:PLACITAS MOUNTAIN MEDICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MARC
Authorized Official - Last Name:BEVERLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-281-5180
Mailing Address - Street 1:12127B HWY 14 N STE 5
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-9499
Mailing Address - Country:US
Mailing Address - Phone:505-281-5180
Mailing Address - Fax:
Practice Address - Street 1:104 QUAIL TRL UNIT B
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015-7185
Practice Address - Country:US
Practice Address - Phone:505-309-0455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PLACITAS MOUNTAIN MEDICAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care