Healthcare Provider Details

I. General information

NPI: 1568221885
Provider Name (Legal Business Name): CORE PRIMARYCARE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1557 MONTE VISTA AVE
LAS CRUCES NM
88001-5731
US

IV. Provider business mailing address

6500 NORTHWEST DR STE 350
MESQUITE TX
75150-1364
US

V. Phone/Fax

Practice location:
  • Phone: 575-571-6946
  • Fax:
Mailing address:
  • Phone: 575-571-6946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: EKEOMA I COOPER
Title or Position: OWNER
Credential: MD
Phone: 575-571-6946