Healthcare Provider Details

I. General information

NPI: 1376774489
Provider Name (Legal Business Name): PHC LAS CRUCES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2009
Last Update Date: 08/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 S TELSHOR BLVD SUITE 201
LAS CRUCES NM
88011-4907
US

IV. Provider business mailing address

2450 S TELSHOR BLVD
LAS CRUCES NM
88011-5069
US

V. Phone/Fax

Practice location:
  • Phone: 575-521-5277
  • Fax:
Mailing address:
  • Phone: 575-521-5277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGIE MANGUM
Title or Position: DIRECTOR
Credential:
Phone: 575-521-5277