Provider Demographics
NPI:1851697429
Name:MAYNES, RAYMOND
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:
Last Name:MAYNES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 ADAMS ST APT G83
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110
Mailing Address - Country:US
Mailing Address - Phone:505-235-0317
Mailing Address - Fax:
Practice Address - Street 1:1709 MOON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-3935
Practice Address - Country:US
Practice Address - Phone:505-271-0329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-31
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1093935959Medicaid