Healthcare Provider Details

I. General information

NPI: 1619974763
Provider Name (Legal Business Name): DR. BRIAN DELAHOUSSAYE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3530 FOOTHILLS RD
LAS CRUCES NM
88011-3621
US

IV. Provider business mailing address

PO BOX 1420
LAS CRUCES NM
88004-1420
US

V. Phone/Fax

Practice location:
  • Phone: 505-532-6054
  • Fax: 505-532-0215
Mailing address:
  • Phone: 505-532-6054
  • Fax: 505-532-0512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY R METCALFE
Title or Position: ASSISTANT ADMINISTRATOR
Credential:
Phone: 505-532-6054