Healthcare Provider Details

I. General information

NPI: 1700422003
Provider Name (Legal Business Name): MARCUS E CARTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2660 EASTMAN AVE SE
ALBUQUERQUE NM
87106-9716
US

IV. Provider business mailing address

2660 EASTMAN AVE SE
ALBUQUERQUE NM
87106-9716
US

V. Phone/Fax

Practice location:
  • Phone: 505-508-3295
  • Fax:
Mailing address:
  • Phone: 505-508-3295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number391830
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-10997
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: