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General NPI Number Information
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NPI Number | 1619647484
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Entity Type | Organization
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Legal Business Name | PINE PSYCHIATRIC CARE SERVICES LLC
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Dates
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Enumeration Date | 09/14/2021
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Last Update Date | 02/14/2023
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Provider Practice Location Address
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Address Line | 500 MARQUETTE AVE NW STE 1200
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City | ALBUQUERQUE
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State | NM
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Zip | 87102-5312
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Country | US
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Telephone | 505-361-6580
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Fax | 505-717-4007
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Provider Business Mailing Address
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Address Line | 500 MARQUETTE AVE NW STE 1200
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City | ALBUQUERQUE
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State | NM
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Zip | 87102-5312
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Country | US
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Telephone | 505-361-6580
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Fax | 505-717-4007
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Authorized Official
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Title or Position | OWNER
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Name | MERCY ITESA
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Credential | PMHNP
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Telephone | 505-361-6580
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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