Healthcare Provider Details

I. General information

NPI: 1063428431
Provider Name (Legal Business Name): MIMBRES HEALTH MAINTENANCE ASSOCIATES P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 08/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W FLORIDA ST
DEMING NM
88030-4558
US

IV. Provider business mailing address

850 W. FLORIDA
DEMING NM
88030
US

V. Phone/Fax

Practice location:
  • Phone: 505-544-2800
  • Fax: 505-544-2801
Mailing address:
  • Phone: 505-544-2800
  • Fax: 505-544-2801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number2003-0634
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number81-71
License Number StateNM

VIII. Authorized Official

Name: DR. GEORGE LAFON
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 505-544-2800