Healthcare Provider Details

I. General information

NPI: 1033444658
Provider Name (Legal Business Name): COMPCARE NEW MEXICO INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2009
Last Update Date: 10/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 LA JOYA ST STE C
ESPANOLA NM
87532-2877
US

IV. Provider business mailing address

706 LA JOYA ST STE C
ESPANOLA NM
87532-2877
US

V. Phone/Fax

Practice location:
  • Phone: 505-367-3547
  • Fax:
Mailing address:
  • Phone: 505-367-3547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberR25973
License Number StateNM

VIII. Authorized Official

Name: LISA GURULE
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 505-367-3547