Healthcare Provider Details

I. General information

NPI: 1417870049
Provider Name (Legal Business Name): RIO RANCHO MEDICAL & INFUSION CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1713 WELLSPRING AVE SE
RIO RANCHO NM
87124-5106
US

IV. Provider business mailing address

6980 OBANNON DR
LAS VEGAS NV
89117-2122
US

V. Phone/Fax

Practice location:
  • Phone: 505-254-1200
  • Fax:
Mailing address:
  • Phone: 702-659-8925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RP1002X
TaxonomyPhysician Nutrition Specialist (Internal Medicine)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number
License Number State

VIII. Authorized Official

Name: DEMETRIUS WARE
Title or Position: CEO
Credential:
Phone: 702-659-8925