Healthcare Provider Details

I. General information

NPI: 1407035124
Provider Name (Legal Business Name): CLINIMED CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6570 4TH ST NW
ALBUQUERQUE NM
87107-5813
US

IV. Provider business mailing address

6570 4TH ST NW
ALBUQUERQUE NM
87107-5813
US

V. Phone/Fax

Practice location:
  • Phone: 505-345-3800
  • Fax: 505-345-7840
Mailing address:
  • Phone: 505-345-3800
  • Fax: 505-345-7840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR 14825
License Number StateNM

VIII. Authorized Official

Name: MR. DONALD MERLE HATHAWAY
Title or Position: OWNER
Credential: C.N.P.
Phone: 505-345-3800