Provider Demographics
NPI:1386823227
Name:ACTION-OCCMED-M.M.I., P.C.
Entity Type:Organization
Organization Name:ACTION-OCCMED-M.M.I., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-556-1011
Mailing Address - Street 1:530 N TELSHOR BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8243
Mailing Address - Country:US
Mailing Address - Phone:575-556-1011
Mailing Address - Fax:575-532-9581
Practice Address - Street 1:530 N TELSHOR BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8243
Practice Address - Country:US
Practice Address - Phone:575-556-1011
Practice Address - Fax:575-532-9581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-28
Last Update Date:2007-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM87-184261QP2300X
NM87-104261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA03175Medicare UPIN