Healthcare Provider Details

I. General information

NPI: 1750767810
Provider Name (Legal Business Name): SOUTHWEST CARE CENTER JEFFERSON ALBUQUERQUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4710 JEFFERSON NE SUITE A
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

PO BOX 6880
SANTA FE NM
87502-6880
US

V. Phone/Fax

Practice location:
  • Phone: 505-955-9454
  • Fax: 505-888-9644
Mailing address:
  • Phone: 505-955-9454
  • Fax: 505-989-8131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL ADAMS
Title or Position: CEO
Credential:
Phone: 505-989-8200