Healthcare Provider Details

I. General information

NPI: 1083483895
Provider Name (Legal Business Name): WELSCARE OF NEW MEXICO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2023
Last Update Date: 01/10/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 JEFFERSON ST NE STE 800
ALBUQUERQUE NM
87109-2132
US

IV. Provider business mailing address

1250 E 3900 S STE 440
SALT LAKE CITY UT
84124-1349
US

V. Phone/Fax

Practice location:
  • Phone: 801-869-4100
  • Fax: 801-869-4119
Mailing address:
  • Phone: 801-869-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA PIKE
Title or Position: ADMIN
Credential:
Phone: 208-982-6734