Healthcare Provider Details

I. General information

NPI: 1043680705
Provider Name (Legal Business Name): HEALOGICS SPECIALTY PHYSICIANS OF NEW MEXICO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2015
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 S TELSHOR BLVD
LAS CRUCES NM
88011-5069
US

IV. Provider business mailing address

5220 BELFORT RD SUITE 130
JACKSONVILLE FL
32256-6017
US

V. Phone/Fax

Practice location:
  • Phone: 904-446-3451
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: LINDA ELLIS
Title or Position: PRESIDENT
Credential:
Phone: 855-689-5105