Healthcare Provider Details

I. General information

NPI: 1003218553
Provider Name (Legal Business Name): INTEGRATED HEALTHCARE OF NEW MEXICO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7632 WILLIAM MOYERS AVE NE
ALBUQUERQUE NM
87122-2765
US

IV. Provider business mailing address

7632 WILLIAM MOYERS AVE NE
ALBUQUERQUE NM
87122-2765
US

V. Phone/Fax

Practice location:
  • Phone: 505-554-1716
  • Fax: 505-792-5222
Mailing address:
  • Phone: 505-554-1716
  • Fax: 505-792-5222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number1251
License Number StateNM

VIII. Authorized Official

Name: DR. STEPHEN L CHESHIRE III
Title or Position: CEO
Credential: PHD
Phone: 505-554-1716