Healthcare Provider Details

I. General information

NPI: 1124744909
Provider Name (Legal Business Name): PHOENIX PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4233 MONTGOMERY BLVD NE STE 140
ALBUQUERQUE NM
87109-6707
US

IV. Provider business mailing address

4233 MONTGOMERY BLVD NE STE 140
ALBUQUERQUE NM
87109-6707
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-1471
  • Fax:
Mailing address:
  • Phone: 505-247-1471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LENA CHAVEZ
Title or Position: OWNER
Credential: FNP
Phone: 505-247-1471