Provider Demographics
NPI:1962685834
Name:OPTUMCARE ENDOSCOPY CENTER NEW MEXICO, LLC
Entity Type:Organization
Organization Name:OPTUMCARE ENDOSCOPY CENTER NEW MEXICO, LLC
Other - Org Name:DAVITA MEDICAL ENDOSCOPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:LIETHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-205-6262
Mailing Address - Street 1:PO BOX 912680
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-4729
Mailing Address - Country:US
Mailing Address - Phone:505-262-7000
Mailing Address - Fax:505-262-7652
Practice Address - Street 1:5400 GIBSON BLVD SE
Practice Address - Street 2:FLOOR 2; ELEVATOR C
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-4729
Practice Address - Country:US
Practice Address - Phone:505-262-7174
Practice Address - Fax:505-262-3562
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAVITA MEDICAL GROUP NEW MEXICO, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-13
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPENDING261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical