Healthcare Provider Details

I. General information

NPI: 1164616892
Provider Name (Legal Business Name): HIGHLANDS SURGICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 11/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 N 3RD AVE
CLAYTON NM
88415-3300
US

IV. Provider business mailing address

315 N 3RD AVE
CLAYTON NM
88415-3300
US

V. Phone/Fax

Practice location:
  • Phone: 505-374-2521
  • Fax: 505-374-2498
Mailing address:
  • Phone: 505-374-2521
  • Fax: 505-374-2498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD2007-0129
License Number StateNM

VIII. Authorized Official

Name: SITARAMAKRISHNA KOTHALANKA
Title or Position: OWNER
Credential: MD
Phone: 505-374-2521