Healthcare Provider Details

I. General information

NPI: 1235686403
Provider Name (Legal Business Name): THE MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2016
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2904 HILLRISE DR
LAS CRUCES NM
88011-4702
US

IV. Provider business mailing address

2904 HILLRISE DR
LAS CRUCES NM
88011-4702
US

V. Phone/Fax

Practice location:
  • Phone: 575-222-4074
  • Fax: 575-222-4078
Mailing address:
  • Phone: 575-222-4074
  • Fax: 575-222-4078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RENE JOUKHADAR
Title or Position: OWNER
Credential: M.D.
Phone: 575-222-4074