Healthcare Provider Details

I. General information

NPI: 1053724682
Provider Name (Legal Business Name): JESSE ORTEGA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 06/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 LOS LENTES RD SE
LOS LUNAS NM
87031-6831
US

IV. Provider business mailing address

1713 SPENCE AVE SE
ALBUQUERQUE NM
87106-4207
US

V. Phone/Fax

Practice location:
  • Phone: 505-916-0632
  • Fax:
Mailing address:
  • Phone: 505-620-4746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: