Provider Demographics
NPI:1629524301
Name:BURBANOMENDOZA, LLC
Entity Type:Organization
Organization Name:BURBANOMENDOZA, LLC
Other - Org Name:SANDIA PSYCHIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURBANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-454-4466
Mailing Address - Street 1:3900 JUAN TABO BLVD NE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3984
Mailing Address - Country:US
Mailing Address - Phone:505-298-1010
Mailing Address - Fax:505-298-3939
Practice Address - Street 1:3900 JUAN TABO BLVD NE
Practice Address - Street 2:SUITE 4
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3984
Practice Address - Country:US
Practice Address - Phone:505-298-1010
Practice Address - Fax:505-298-3939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2013-09642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty