Healthcare Provider Details

I. General information

NPI: 1619647484
Provider Name (Legal Business Name): PINE PSYCHIATRIC CARE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2021
Last Update Date: 02/14/2023
Certification Date: 02/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MARQUETTE AVE NW STE 1200
ALBUQUERQUE NM
87102-5312
US

IV. Provider business mailing address

500 MARQUETTE AVE NW STE 1200
ALBUQUERQUE NM
87102-5312
US

V. Phone/Fax

Practice location:
  • Phone: 505-361-6580
  • Fax: 505-717-4007
Mailing address:
  • Phone: 505-361-6580
  • Fax: 505-717-4007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MERCY ITESA
Title or Position: OWNER
Credential: PMHNP
Phone: 505-361-6580