Provider Demographics
NPI:1568461911
Name:CASA ALEGRE PEDIATRICS, LLC
Entity Type:Organization
Organization Name:CASA ALEGRE PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:505-532-5912
Mailing Address - Street 1:532 N TELSHOR BLVD
Mailing Address - Street 2:SUITE G
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8234
Mailing Address - Country:US
Mailing Address - Phone:505-532-5912
Mailing Address - Fax:505-532-5915
Practice Address - Street 1:532 N TELSHOR BLVD
Practice Address - Street 2:SUITE G
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8234
Practice Address - Country:US
Practice Address - Phone:505-532-5912
Practice Address - Fax:505-532-5915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA105096208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMJ6791Medicaid
NMJ6791Medicaid