Provider Demographics
NPI:1790196665
Name:MISSION HEALTH ALLIANCE LLC
Entity Type:Organization
Organization Name:MISSION HEALTH ALLIANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:LOGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:575-649-5898
Mailing Address - Street 1:2407 W PICACHO AVE
Mailing Address - Street 2:A109
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88007-4124
Mailing Address - Country:US
Mailing Address - Phone:575-649-5898
Mailing Address - Fax:575-652-4555
Practice Address - Street 1:2407 W PICACHO AVE
Practice Address - Street 2:A109
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88007-4124
Practice Address - Country:US
Practice Address - Phone:575-649-5898
Practice Address - Fax:575-652-4555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty