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General NPI Number Information
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NPI Number | 1649834904
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Entity Type | Organization
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Legal Business Name | MEDERI LIFE LLC
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Dates
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Enumeration Date | 04/23/2019
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Last Update Date | 10/04/2021
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Provider Practice Location Address
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Address Line | 6200 COORS BLVD NW STE A8
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City | ALBUQUERQUE
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State | NM
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Zip | 87120-2794
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Country | US
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Telephone | 505-433-4007
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Fax | 505-433-4068
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Provider Business Mailing Address
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Address Line | 6200 COORS BLVD NW STE A8
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City | ALBUQUERQUE
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State | NM
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Zip | 87120-2794
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Country | US
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Telephone | 505-433-4007
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Fax | 505-433-4068
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Authorized Official
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Title or Position | MANAGER
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Name | LISA PADILLA
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Credential |
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Telephone | 505-385-9060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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