Healthcare Provider Details

I. General information

NPI: 1609418144
Provider Name (Legal Business Name): PIVOT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2019
Last Update Date: 01/16/2020
Certification Date: 01/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 CENTRAL AVE SE
ALBUQUERQUE NM
87106-4411
US

IV. Provider business mailing address

1620 CENTRAL AVE SE
ALBUQUERQUE NM
87106-4411
US

V. Phone/Fax

Practice location:
  • Phone: 585-202-9180
  • Fax:
Mailing address:
  • Phone: 585-202-9180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: AMY M HUDAK
Title or Position: ADMINISTRATIVE MANAGER
Credential:
Phone: 505-551-0220