Provider Demographics
NPI:1336334127
Name:ACADEMY ORTHOPAEDIC CLINIC LLC
Entity Type:Organization
Organization Name:ACADEMY ORTHOPAEDIC CLINIC LLC
Other - Org Name:THOMAS GRACE, MD
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:FRIEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-821-6663
Mailing Address - Street 1:8301 SPAIN RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3166
Mailing Address - Country:US
Mailing Address - Phone:505-821-6663
Mailing Address - Fax:505-823-2683
Practice Address - Street 1:8301 SPAIN RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3166
Practice Address - Country:US
Practice Address - Phone:505-821-6663
Practice Address - Fax:505-823-2683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM77-38174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM007588OtherBC/BS OF NM
NM000F0316Medicaid
NM400521083Medicare PIN
NMD35664Medicare UPIN
NM000F0316Medicaid