Provider Demographics
NPI:1225389919
Name:MAIN STREET MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:MAIN STREET MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CROSS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:575-754-6330
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:RED RIVER
Mailing Address - State:NM
Mailing Address - Zip Code:87558-0010
Mailing Address - Country:US
Mailing Address - Phone:575-779-8015
Mailing Address - Fax:
Practice Address - Street 1:200 PIONEER RD
Practice Address - Street 2:STE A
Practice Address - City:RED RIVER
Practice Address - State:NM
Practice Address - Zip Code:87558-0010
Practice Address - Country:US
Practice Address - Phone:575-754-6330
Practice Address - Fax:575-754-6232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-21
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
NMCNP-01822363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1225389919OtherORG 2 NPI