Healthcare Provider Details

I. General information

NPI: 1962685834
Provider Name (Legal Business Name): OPTUMCARE ENDOSCOPY CENTER NEW MEXICO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2007
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 GIBSON BLVD SE FLOOR 2; ELEVATOR C
ALBUQUERQUE NM
87108-4729
US

IV. Provider business mailing address

PO BOX 912680
DENVER CO
80291-4729
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-7174
  • Fax: 505-262-3562
Mailing address:
  • Phone: 505-262-7000
  • Fax: 505-262-7652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberPENDING
License Number StateNM

VIII. Authorized Official

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