Healthcare Provider Details

I. General information

NPI: 1700286960
Provider Name (Legal Business Name): MAX ORTIZ CONCHA LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2014
Last Update Date: 08/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 UPTOWN BLVD NE
ALBUQUERQUE NM
87110-4204
US

IV. Provider business mailing address

6400 UPTOWN BLVD NE
ALBUQUERQUE NM
87110-4204
US

V. Phone/Fax

Practice location:
  • Phone: 505-855-9805
  • Fax: 505-848-9468
Mailing address:
  • Phone: 505-855-9805
  • Fax: 505-848-9468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberI-06879
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: