Provider Demographics
NPI:1598352015
Name:ELITE PATIENT CARE NEW MEXICO LLC
Entity Type:Organization
Organization Name:ELITE PATIENT CARE NEW MEXICO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMBOA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-408-0797
Mailing Address - Street 1:1509 DULLES DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-3718
Mailing Address - Country:US
Mailing Address - Phone:337-408-0797
Mailing Address - Fax:
Practice Address - Street 1:206 S CORONADO AVE
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2792
Practice Address - Country:US
Practice Address - Phone:337-408-0797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-30
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty