Provider Demographics
NPI:1649782962
Name:MOLINA HEALTHCARE OF NEW MEXICO
Entity type:Organization
Organization Name:MOLINA HEALTHCARE OF NEW MEXICO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PLAN PRESIDENT-MHNM
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SORRELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-562-5442
Mailing Address - Street 1:200 OCEANGATE STE 100
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:888-562-5442
Mailing Address - Fax:
Practice Address - Street 1:400 TIJERAS AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3234
Practice Address - Country:US
Practice Address - Phone:888-562-5441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOLINA HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty