Provider Demographics
NPI:1417927021
Name:HEART HOSPITAL OF NEW MEXICO, LLC
Entity Type:Organization
Organization Name:HEART HOSPITAL OF NEW MEXICO, LLC
Other - Org Name:HEART HOSPITAL OF NEW MEXICO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, BUSINESS OFFICE OPERATION
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:FENTEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-702-7500
Mailing Address - Street 1:PO BOX 50270
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0001
Mailing Address - Country:US
Mailing Address - Phone:505-724-2000
Mailing Address - Fax:
Practice Address - Street 1:504 ELM ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2512
Practice Address - Country:US
Practice Address - Phone:505-724-2000
Practice Address - Fax:505-246-9933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6782282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM72264Medicaid
320083Medicare Oscar/Certification