Provider Demographics
NPI:1245478270
Name:NEW MEXICO CHILDRENS KIDNEY CENTER
Entity type:Organization
Organization Name:NEW MEXICO CHILDRENS KIDNEY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC NEPHROLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:505-797-8676
Mailing Address - Street 1:PO BOX 1560
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88004-1560
Mailing Address - Country:US
Mailing Address - Phone:505-842-5240
Mailing Address - Fax:505-242-4403
Practice Address - Street 1:4343 PAN AMERICAN FWY NE
Practice Address - Street 2:#234
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-6834
Practice Address - Country:US
Practice Address - Phone:505-842-5240
Practice Address - Fax:505-242-4403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-29
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM98-339174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty