Healthcare Provider Details

I. General information

NPI: 1205413168
Provider Name (Legal Business Name): HIGH DESERT PALLIATIVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 03/26/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8661 SAN PEDRO DR NE
ALBUQUERQUE NM
87113-1942
US

IV. Provider business mailing address

8661 SAN PEDRO DR NE
ALBUQUERQUE NM
87113-1942
US

V. Phone/Fax

Practice location:
  • Phone: 505-585-2603
  • Fax:
Mailing address:
  • Phone: 505-585-2603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DEREK SORENSEN
Title or Position: MEMBER
Credential:
Phone: 435-669-4510