=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134790462
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOUNTAIN VIEW FAMILY MEDICINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2021
-----------------------------------------------------
Last Update Date | 12/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4600 MONTGOMERY BLVD NE STE D201
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109-1211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-610-1155
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 703 CHARLES PL NW
-----------------------------------------------------
City | LOS RANCHOS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87107-6224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-297-7759
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MATTHEW DAVID TOTTER
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 505-884-0079
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------