Provider Demographics
NPI:1316218126
Name:ALLERGY CLINIC OF AMERICA, LLC.
Entity Type:Organization
Organization Name:ALLERGY CLINIC OF AMERICA, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NII
Authorized Official - Middle Name:TETTEH
Authorized Official - Last Name:ADDY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:575-887-1282
Mailing Address - Street 1:615 W MERMOD ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-4912
Mailing Address - Country:US
Mailing Address - Phone:575-887-8925
Mailing Address - Fax:575-887-8935
Practice Address - Street 1:615 W MERMOD ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-4912
Practice Address - Country:US
Practice Address - Phone:575-887-8925
Practice Address - Fax:575-887-8935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2A-1299-05207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM88003791Medicaid