Healthcare Provider Details

I. General information

NPI: 1013367440
Provider Name (Legal Business Name): CAPERTON FERTILITY INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 06/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 JEFFERSON ST NE STE 250
ALBUQUERQUE NM
87109-3490
US

IV. Provider business mailing address

6500 JEFFERSON ST NE STE 250
ALBUQUERQUE NM
87109-3490
US

V. Phone/Fax

Practice location:
  • Phone: 505-702-8020
  • Fax: 505-796-8022
Mailing address:
  • Phone: 505-702-8020
  • Fax: 505-796-8022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberMD2005-0092
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD2005-0092
License Number StateNM

VIII. Authorized Official

Name: CHARLES CAPERTON II
Title or Position: OWNER
Credential: MD
Phone: 505-553-3535