Healthcare Provider Details

I. General information

NPI: 1720643323
Provider Name (Legal Business Name): SOUTHERN NEW MEXICO FAMILY NEUROLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 05/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 MISSOURI AVE STE 12
LAS CRUCES NM
88011-5061
US

IV. Provider business mailing address

1180 COMMERCE DR UNIT 13028
LAS CRUCES NM
88011-8210
US

V. Phone/Fax

Practice location:
  • Phone: 718-570-6086
  • Fax:
Mailing address:
  • Phone: 718-570-6086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MISS ROCCO FRANCO
Title or Position: PRESIDENT AND SOLE SHAREHOLDER
Credential: MD
Phone: 718-570-6086