Healthcare Provider Details

I. General information

NPI: 1699517771
Provider Name (Legal Business Name): SPECIALTY CARE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2024
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3825 EUBANK BLVD NE STE H
ALBUQUERQUE NM
87111-3559
US

IV. Provider business mailing address

3825 EUBANK BLVD NE STE H
ALBUQUERQUE NM
87111-3559
US

V. Phone/Fax

Practice location:
  • Phone: 505-350-3397
  • Fax: 505-323-7980
Mailing address:
  • Phone: 505-350-3397
  • Fax: 505-323-7980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN K JAIN
Title or Position: OWNER CEO
Credential:
Phone: 505-350-3397