Healthcare Provider Details

I. General information

NPI: 1740708809
Provider Name (Legal Business Name): 11.11, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11724 COPPER PL NE
ALBUQUERQUE NM
87123
US

IV. Provider business mailing address

11724 COPPER PL NE
ALBUQUERQUE NM
87123-1312
US

V. Phone/Fax

Practice location:
  • Phone: 505-226-1276
  • Fax:
Mailing address:
  • Phone: 505-226-1276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: MR. JACOB N PATTERSON
Title or Position: OWNER
Credential:
Phone: 505-226-1276