Healthcare Provider Details

I. General information

NPI: 1770064743
Provider Name (Legal Business Name): INVICTUS HEALTHCARE MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 RED ROCK DR
GALLUP NM
87301-5683
US

IV. Provider business mailing address

2418 E. HWY 66 PMB 496
GALLUP NM
87301
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-7030
  • Fax: 505-863-5806
Mailing address:
  • Phone: 915-525-3370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number StateNM

VIII. Authorized Official

Name: MRS. JASMINE KIEFER
Title or Position: VP OF OPERATIONS
Credential:
Phone: 915-525-3370