Provider Demographics
NPI:1578027470
Name:PURE HEALTHCARE OF NEW MEXICO LLC
Entity Type:Organization
Organization Name:PURE HEALTHCARE OF NEW MEXICO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING CONTRACTING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-590-9267
Mailing Address - Street 1:4179 S RIVERBOAT RD STE 220
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-2986
Mailing Address - Country:US
Mailing Address - Phone:801-755-3387
Mailing Address - Fax:
Practice Address - Street 1:1648B ALAMEDA BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-8807
Practice Address - Country:US
Practice Address - Phone:505-966-9644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-24
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy