Provider Demographics
NPI:1942292149
Name:IMMEDICARE CARE CLINIC PC
Entity Type:Organization
Organization Name:IMMEDICARE CARE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:NISHITANI
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:505-630-5300
Mailing Address - Street 1:721 MECHEM DR
Mailing Address - Street 2:SIERRA MALL
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-6911
Mailing Address - Country:US
Mailing Address - Phone:505-630-5300
Mailing Address - Fax:505-630-5301
Practice Address - Street 1:721 MECHEM DR
Practice Address - Street 2:SIERRA MALL
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6911
Practice Address - Country:US
Practice Address - Phone:505-630-5300
Practice Address - Fax:505-630-5301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM36888257Medicaid