Healthcare Provider Details

I. General information

NPI: 1386823227
Provider Name (Legal Business Name): ACTION-OCCMED-M.M.I., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2007
Last Update Date: 10/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 N TELSHOR BLVD SUITE B
LAS CRUCES NM
88011-8243
US

IV. Provider business mailing address

530 N TELSHOR BLVD SUITE B
LAS CRUCES NM
88011-8243
US

V. Phone/Fax

Practice location:
  • Phone: 575-556-1011
  • Fax: 575-532-9581
Mailing address:
  • Phone: 575-556-1011
  • Fax: 575-532-9581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number87-104
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number87-184
License Number StateNM

VIII. Authorized Official

Name: DR. EDWIN LEE KENNEDY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 575-556-1011