Healthcare Provider Details

I. General information

NPI: 1568461911
Provider Name (Legal Business Name): CASA ALEGRE PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532 N TELSHOR BLVD SUITE G
LAS CRUCES NM
88011-8234
US

IV. Provider business mailing address

532 N TELSHOR BLVD SUITE G
LAS CRUCES NM
88011-8234
US

V. Phone/Fax

Practice location:
  • Phone: 505-532-5912
  • Fax: 505-532-5915
Mailing address:
  • Phone: 505-532-5912
  • Fax: 505-532-5915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA105096
License Number StateNM

VIII. Authorized Official

Name: DR. JOANNE M RAY
Title or Position: PRESIDENT
Credential: DO
Phone: 505-532-5912