Healthcare Provider Details

I. General information

NPI: 1194150318
Provider Name (Legal Business Name): MOLINA MEDICAL GROUP OF NEW MEXICO, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2013
Last Update Date: 05/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1714 SAINT MICHAELS DR # 1
SANTA FE NM
87505-7617
US

IV. Provider business mailing address

200 OCEANGATE SUITE 100
LONG BEACH CA
90802-4317
US

V. Phone/Fax

Practice location:
  • Phone: 505-490-4042
  • Fax: 877-846-3680
Mailing address:
  • Phone: 505-490-4042
  • Fax: 562-499-6171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNM
# 5
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNM
# 6
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNM

VIII. Authorized Official

Name: GLORIA CALDERON
Title or Position: VP, CLINIC OPERATIONS
Credential:
Phone: 562-499-6191