Provider Demographics
NPI:1932650041
Name:AZURITE SERVICES PC
Entity Type:Organization
Organization Name:AZURITE SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BETHANY
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:575-317-7934
Mailing Address - Street 1:PO BOX 2406
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-2406
Mailing Address - Country:US
Mailing Address - Phone:575-208-0106
Mailing Address - Fax:
Practice Address - Street 1:613 W 2ND ST STE 1
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4671
Practice Address - Country:US
Practice Address - Phone:575-755-5555
Practice Address - Fax:575-755-5556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-24
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP02864364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Multi-Specialty