Provider Demographics
NPI:1114220316
Name:ULTIMED RED RIVER, INC.
Entity Type:Organization
Organization Name:ULTIMED RED RIVER, INC.
Other - Org Name:ULTIMED ANGEL FIRE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LESA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-989-8707
Mailing Address - Street 1:707 PASEO DE PERALTA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1922
Mailing Address - Country:US
Mailing Address - Phone:505-989-8707
Mailing Address - Fax:505-989-3536
Practice Address - Street 1:37 ASPEN
Practice Address - Street 2:
Practice Address - City:ANGEL FIRE
Practice Address - State:NM
Practice Address - Zip Code:87710-0000
Practice Address - Country:US
Practice Address - Phone:575-754-1773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TAOS COMPREHENSIVE HEALTH CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-09
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care