MEDICARE: TURQUOISE TRAIL PRIMARY CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1902324692
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TURQUOISE TRAIL PRIMARY CARE LLC

Provider Business Mailing Address
First Line	:	3825 EUBANK BLVD NE STE C
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111-3559
Country	:	US
Telephone Number	:	505-702-1117
Fax Number	:	505-433-3299

Provider Business Practice Location Address
First Line	:	3825 EUBANK BLVD NE STE C
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111-3559
Country	:	US
Telephone Number	:	505-702-1117
Fax Number	:	505-433-3299

Authorized Official
Title or Position	:	COO
Name	:	MRS. ELIZABETH RENEE DUNAGAN
Credential	:	MA
Telephone Number	:	505-702-1117

Provider Enumeration Date	:	09/01/2017
Last Update Date	:	07/21/2022

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