Healthcare Provider Details

I. General information

NPI: 1154785640
Provider Name (Legal Business Name): EXTENDED HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 04/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 VERANDA RD NW
ALBUQUERQUE NM
87107-2940
US

IV. Provider business mailing address

2600 VERANDA RD NW
ALBUQUERQUE NM
87107-2940
US

V. Phone/Fax

Practice location:
  • Phone: 505-414-3996
  • Fax:
Mailing address:
  • Phone: 505-414-3996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOAN PATRICIA LEWIS
Title or Position: CEO
Credential: MD
Phone: 505-414-3996