Healthcare Provider Details

I. General information

NPI: 1720291529
Provider Name (Legal Business Name): AFFILION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4311 E LOHMAN AVE
LAS CRUCES NM
88011
US

IV. Provider business mailing address

13737 NOEL RD STE 1600
DALLAS TX
75240-1331
US

V. Phone/Fax

Practice location:
  • Phone: 505-556-6800
  • Fax:
Mailing address:
  • Phone: 973-251-1132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier15334821
Identifier TypeMEDICAID
Identifier StateNM
Identifier Issuer
# 2
IdentifierNM007F22
Identifier TypeOTHER
Identifier StateNM
Identifier IssuerBCBS NM

VIII. Authorized Official

Name: KATHY KONDAS
Title or Position: OFFICER
Credential:
Phone: 973-251-1132