Healthcare Provider Details

I. General information

NPI: 1184956922
Provider Name (Legal Business Name): PINNACLE FAMILY HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2010
Last Update Date: 02/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4351 E LOHMAN AVE SUITE 405
LAS CRUCES NM
88011-8259
US

IV. Provider business mailing address

4351 E LOHMAN AVE SUITE 405
LAS CRUCES NM
88011-8259
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-0091
  • Fax: 575-522-4984
Mailing address:
  • Phone: 575-522-0091
  • Fax: 575-522-4984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberNM20060321
License Number StateNM

VIII. Authorized Official

Name: DR. MARK CORNELIUS LEATHERWOOD
Title or Position: OWNER
Credential: MD
Phone: 575-522-0091