Healthcare Provider Details

I. General information

NPI: 1245920396
Provider Name (Legal Business Name): PEDS TOTS TO TEENS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 MALL DR
LAS CRUCES NM
88011-8101
US

IV. Provider business mailing address

1180 MALL DR
LAS CRUCES NM
88011-8101
US

V. Phone/Fax

Practice location:
  • Phone: 575-259-3785
  • Fax: 575-532-9221
Mailing address:
  • Phone: 575-259-3785
  • Fax: 575-532-9221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. USHA PHILLIPS
Title or Position: OWNER
Credential: MD
Phone: 575-259-3785