Healthcare Provider Details

I. General information

NPI: 1245494723
Provider Name (Legal Business Name): OPTUMCARE NEW MEXICO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2008
Last Update Date: 08/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 JOURNAL CENTER BLVD NE
ALBUQUERQUE NM
87109-5900
US

IV. Provider business mailing address

PO BOX 26028
ALBUQUERQUE NM
87125-6028
US

V. Phone/Fax

Practice location:
  • Phone: 505-232-1500
  • Fax: 505-232-1584
Mailing address:
  • Phone: 505-232-1500
  • Fax: 505-232-1584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2471V0106X
TaxonomyVascular-Interventional Technology Radiologic Technologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2471B0102X
TaxonomyBone Densitometry Radiologic Technologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2471M1202X
TaxonomyMagnetic Resonance Imaging Radiologic Technologist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2471M2300X
TaxonomyMammography Radiologic Technologist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name: JOHN G LIETHEN
Title or Position: SECRETARY
Credential:
Phone: 952-205-6262