Provider Demographics
NPI:1376722827
Name:MEDICINE CLINIC LLC
Entity Type:Organization
Organization Name:MEDICINE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERNAL MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:J
Authorized Official - Last Name:FONSECA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-392-8943
Mailing Address - Street 1:5419 N LOVINGTON HWY STE 10
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-9135
Mailing Address - Country:US
Mailing Address - Phone:505-392-8943
Mailing Address - Fax:505-392-8960
Practice Address - Street 1:5419 N LOVINGTON HWY STE 10
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-9135
Practice Address - Country:US
Practice Address - Phone:505-392-8943
Practice Address - Fax:505-392-8960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM009390OtherBCBS
NMNM009390OtherBCBS