Provider Demographics
NPI:1508021627
Name:NEW MEXICO MOUNTAIN HEALTHCARE
Entity Type:Organization
Organization Name:NEW MEXICO MOUNTAIN HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:DUMAL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-404-6048
Mailing Address - Street 1:348 ST. RD. 4
Mailing Address - Street 2:
Mailing Address - City:SAN YSIDRO
Mailing Address - State:NM
Mailing Address - Zip Code:87053
Mailing Address - Country:US
Mailing Address - Phone:505-404-6048
Mailing Address - Fax:
Practice Address - Street 1:348 ST. RD. 4
Practice Address - Street 2:
Practice Address - City:SAN YSIDRO
Practice Address - State:NM
Practice Address - Zip Code:87053
Practice Address - Country:US
Practice Address - Phone:505-404-6048
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-29
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM97-229261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health