Healthcare Provider Details

I. General information

NPI: 1750653069
Provider Name (Legal Business Name): MOLINA HEALTHCARE OF NEW MEXICO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2012
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7317 CENTRAL NE
ALBUQUERQUE NM
87108-2015
US

IV. Provider business mailing address

100 OCEANGATE SUITE 100
LONG BEACH CA
90802-4317
US

V. Phone/Fax

Practice location:
  • Phone: 505-553-1630
  • Fax: 562-499-6171
Mailing address:
  • Phone: 562-499-6191
  • Fax: 562-499-6171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TINA M PADRON
Title or Position: AFC, WESTERN REGIONAL DIRECTOR CLIN
Credential:
Phone: 562-499-6191