Healthcare Provider Details

I. General information

NPI: 1831478445
Provider Name (Legal Business Name): NICHOLAS DEMECIO MEDINA A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2011
Last Update Date: 08/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7007 JEFFERSON ST NE STE C
ALBUQUERQUE NM
87109-4450
US

IV. Provider business mailing address

7007 JEFFERSON ST NE STE C
ALBUQUERQUE NM
87109-4450
US

V. Phone/Fax

Practice location:
  • Phone: 505-821-4325
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number493
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: