Healthcare Provider Details

I. General information

NPI: 1083385132
Provider Name (Legal Business Name): CHARLES MCNAMARA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2021
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 OAK ST
LAS CRUCES NM
88005-3425
US

IV. Provider business mailing address

3100 OAK ST
LAS CRUCES NM
88005-3425
US

V. Phone/Fax

Practice location:
  • Phone: 575-523-2288
  • Fax:
Mailing address:
  • Phone: 575-523-2288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-11800
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: