Healthcare Provider Details

I. General information

NPI: 1366877581
Provider Name (Legal Business Name): MOLINA MEDICAL GROUP OF NEW MEXICO, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2013
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7317 CENTRAL AVE NE
ALBUQUERQUE NM
87108-2015
US

IV. Provider business mailing address

200 OCEANGATE SUITE 100
LONG BEACH CA
90802-4317
US

V. Phone/Fax

Practice location:
  • Phone: 505-200-3320
  • Fax: 877-860-2279
Mailing address:
  • Phone: 505-200-3320
  • Fax: 562-499-6171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GLORIA CALDERON
Title or Position: VP, CLINIC OPERATIONS
Credential:
Phone: 562-499-6191