Healthcare Provider Details

I. General information

NPI: 1588063143
Provider Name (Legal Business Name): ALBUQUERQUE WESTSIDE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2014
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 UNSER BLVD NW
ALBUQUERQUE NM
87121-1969
US

IV. Provider business mailing address

300 UNSER BLVD NW
ALBUQUERQUE NM
87121-1969
US

V. Phone/Fax

Practice location:
  • Phone: 505-839-5282
  • Fax: 505-831-4503
Mailing address:
  • Phone: 505-839-5282
  • Fax: 505-831-4503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number StateNM

VIII. Authorized Official

Name: BARRY L. BLANTON
Title or Position: VICE PRESIDENT
Credential:
Phone: 781-699-9000