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General NPI Number Information
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NPI Number | 1245478270
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Entity Type | Organization
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Legal Business Name | NEW MEXICO CHILDRENS KIDNEY CENTER
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Dates
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Enumeration Date | 01/29/2009
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Last Update Date | 10/06/2015
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Provider Practice Location Address
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Address Line | 4343 PAN AMERICAN FWY NE #234
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City | ALBUQUERQUE
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State | NM
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Zip | 87107-6834
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Country | US
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Telephone | 505-842-5240
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Fax | 505-242-4403
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Provider Business Mailing Address
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Address Line | PO BOX 1560
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City | LAS CRUCES
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State | NM
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Zip | 88004-1560
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Country | US
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Telephone | 505-842-5240
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Fax | 505-242-4403
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Authorized Official
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Title or Position | PEDIATRIC NEPHROLOGY
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Name | DR. ROBERT BENJAMIN MILLER III
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Credential | M.D.
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Telephone | 505-797-8676
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 98-339
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License Number State | NM
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