Provider Demographics
NPI:1073594446
Name:SOUTHEASTERN NEW MEXICO SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHEASTERN NEW MEXICO SURGICAL CENTER, LLC
Other - Org Name:CENTER FOR AMBULATORY SURGERY AND ENDOSCOPY OF SOUTHEASTERN NEW MEXICO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURI
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, CASC
Authorized Official - Phone:505-627-7000
Mailing Address - Street 1:113 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5151
Mailing Address - Country:US
Mailing Address - Phone:505-627-7000
Mailing Address - Fax:505-627-7007
Practice Address - Street 1:113 E 19TH ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5151
Practice Address - Country:US
Practice Address - Phone:505-627-7000
Practice Address - Fax:505-627-7007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6786261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM74469Medicaid