Healthcare Provider Details

I. General information

NPI: 1851697429
Provider Name (Legal Business Name): MR. RAYMOND MAYNES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2011
Last Update Date: 01/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 MOON ST NE
ALBUQUERQUE NM
87112-3935
US

IV. Provider business mailing address

3131 ADAMS ST APT G83
ALBUQUERQUE NM
87110
US

V. Phone/Fax

Practice location:
  • Phone: 505-271-0329
  • Fax:
Mailing address:
  • Phone: 505-235-0317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: