Provider Demographics
NPI:1457636706
Name:ALTEON HEALTH NEW MEXICO LLC
Entity Type:Organization
Organization Name:ALTEON HEALTH NEW MEXICO LLC
Other - Org Name:ISLAND MEDICAL LOE LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PROVIDER ENROLLMENT OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:REESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-687-0618
Mailing Address - Street 1:4535 DRESSLER RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2545
Mailing Address - Country:US
Mailing Address - Phone:330-994-4409
Mailing Address - Fax:330-492-8489
Practice Address - Street 1:5419 N LOVINGTON HWY
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-9100
Practice Address - Country:US
Practice Address - Phone:844-474-4019
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM58674853Medicaid