Provider Demographics
NPI:1083197032
Name:DAVITA MEDICAL GROUP NEW MEXICO, LLC
Entity Type:Organization
Organization Name:DAVITA MEDICAL GROUP NEW MEXICO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-876-6457
Mailing Address - Street 1:PO BOX 26028
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6028
Mailing Address - Country:US
Mailing Address - Phone:505-262-3135
Mailing Address - Fax:
Practice Address - Street 1:5150 JOURNAL CENTER BLVD NE FL 2
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5900
Practice Address - Country:US
Practice Address - Phone:505-232-1530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAVITA MEDICAL GROUP NEW MEXICO, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies