Healthcare Provider Details

I. General information

NPI: 1902333776
Provider Name (Legal Business Name): PLACITAS MOUNTAIN MEDICAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 QUAIL TRL UNIT B
EDGEWOOD NM
87015-7185
US

IV. Provider business mailing address

12127B HWY 14 N STE 5
CEDAR CREST NM
87008-9499
US

V. Phone/Fax

Practice location:
  • Phone: 505-309-0455
  • Fax:
Mailing address:
  • Phone: 505-281-5180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMES MARC BEVERLY
Title or Position: OWNER
Credential:
Phone: 505-281-5180