Provider Demographics
NPI:1316545882
Name:KINGSLEY CLINIC OF NEW MEXICO, LLC
Entity Type:Organization
Organization Name:KINGSLEY CLINIC OF NEW MEXICO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:KINGSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-405-3617
Mailing Address - Street 1:6300 RIVERSIDE PLAZA LN NW STE 100
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1908
Mailing Address - Country:US
Mailing Address - Phone:505-405-3617
Mailing Address - Fax:
Practice Address - Street 1:6300 RIVERSIDE PLAZA LN NW STE 100
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-1908
Practice Address - Country:US
Practice Address - Phone:505-405-3617
Practice Address - Fax:505-370-2053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care