Provider Demographics
NPI:1497280143
Name:SANDIA MOUNTAIN MEDICAL, INC.
Entity Type:Organization
Organization Name:SANDIA MOUNTAIN MEDICAL, INC.
Other - Org Name:NEW MEXICO MEDICAL URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MARC
Authorized Official - Last Name:BEVERLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-281-5180
Mailing Address - Street 1:12127B HWY 14 N STE 5
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008
Mailing Address - Country:US
Mailing Address - Phone:505-281-5180
Mailing Address - Fax:505-281-5320
Practice Address - Street 1:104 QUAIL TRL UNIT B
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015-7185
Practice Address - Country:US
Practice Address - Phone:505-281-5180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SANDIA MOUNTAIN MEDICAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-01
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM02478261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care