Provider Demographics
NPI:1265502298
Name:SOUTHWEST HEART PC
Entity type:Organization
Organization Name:SOUTHWEST HEART PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOULWARE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-522-7247
Mailing Address - Street 1:4351 E LOHMAN AVE STE 405
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8261
Mailing Address - Country:US
Mailing Address - Phone:575-522-2233
Mailing Address - Fax:575-522-2266
Practice Address - Street 1:4351 E LOHMAN AVE STE 405
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8261
Practice Address - Country:US
Practice Address - Phone:575-522-2233
Practice Address - Fax:575-522-2266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM56428006Medicaid
NM33087512Medicaid
NM400521229Medicare ID - Type Unspecified
NM33087512Medicaid