Provider Demographics
NPI:1164475828
Name:PC MARK RACE MD PLC
Entity Type:Organization
Organization Name:PC MARK RACE MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:RACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-446-5900
Mailing Address - Street 1:1501 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-5044
Mailing Address - Country:US
Mailing Address - Phone:575-446-5900
Mailing Address - Fax:575-446-5939
Practice Address - Street 1:1501 10TH ST
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-5044
Practice Address - Country:US
Practice Address - Phone:575-446-5900
Practice Address - Fax:575-446-5939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2009-0724174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0417253Medicaid
IA1175OtherMIDLANDS
IA0417253Medicaid
IAI9624Medicare ID - Type Unspecified