Healthcare Provider Details

I. General information

NPI: 1649782962
Provider Name (Legal Business Name): MOLINA HEALTHCARE OF NEW MEXICO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 10/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 TIJERAS AVE NW
ALBUQUERQUE NM
87102-3234
US

IV. Provider business mailing address

200 OCEANGATE STE 100
LONG BEACH CA
90802-4317
US

V. Phone/Fax

Practice location:
  • Phone: 888-562-5441
  • Fax:
Mailing address:
  • Phone: 888-562-5442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIEL SORRELLS
Title or Position: PLAN PRESIDENT-MHNM
Credential:
Phone: 888-562-5442