Provider Demographics
NPI:1184956922
Name:PINNACLE FAMILY HEALTHCARE
Entity type:Organization
Organization Name:PINNACLE FAMILY HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:CORNELIUS
Authorized Official - Last Name:LEATHERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-522-0091
Mailing Address - Street 1:4351 E LOHMAN AVE
Mailing Address - Street 2:SUITE 405
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8259
Mailing Address - Country:US
Mailing Address - Phone:575-522-0091
Mailing Address - Fax:575-522-4984
Practice Address - Street 1:4351 E LOHMAN AVE
Practice Address - Street 2:SUITE 405
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8259
Practice Address - Country:US
Practice Address - Phone:575-522-0091
Practice Address - Fax:575-522-4984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM20060321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMII56889Medicare UPIN