Provider Demographics
NPI:1669736328
Name:MMC CANCER CENTER
Entity type:Organization
Organization Name:MMC CANCER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:HERZOG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-521-2258
Mailing Address - Street 1:2530 S TELSHOR BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4975
Mailing Address - Country:US
Mailing Address - Phone:575-521-1554
Mailing Address - Fax:575-556-1754
Practice Address - Street 1:2530 S TELSHOR BLVD STE 201
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4975
Practice Address - Country:US
Practice Address - Phone:575-521-1554
Practice Address - Fax:575-556-1754
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0110081273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
LPCC 0110081OtherNEW MEXICO LICENSE FROM THE COUNSELING AND THERAPY PRACTICE BOARD