Healthcare Provider Details

I. General information

NPI: 1326338963
Provider Name (Legal Business Name): OPTUMCARE NEW MEXICO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2011
Last Update Date: 08/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 GIBSON BLVD SE
ALBUQUERQUE NM
87108-4729
US

IV. Provider business mailing address

PO BOX 27007
ALBUQUERQUE NM
87125-7007
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-7026
  • Fax:
Mailing address:
  • Phone: 724-971-3329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number01759
License Number StateNM

VIII. Authorized Official

Name: JOHN G LIETHEN
Title or Position: SECRETARY
Credential:
Phone: 952-205-6262