Provider Demographics
NPI:1740951672
Name:HUMAN MILK REPOSITORY OF NEW MEXICO
Entity type:Organization
Organization Name:HUMAN MILK REPOSITORY OF NEW MEXICO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ASHTON
Authorized Official - Middle Name:
Authorized Official - Last Name:LINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-489-5600
Mailing Address - Street 1:6208 MONTGOMERY BLVD NE STE D
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1400
Mailing Address - Country:US
Mailing Address - Phone:505-508-5291
Mailing Address - Fax:
Practice Address - Street 1:6208 MONTGOMERY BLVD NE STE D
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1400
Practice Address - Country:US
Practice Address - Phone:505-508-5291
Practice Address - Fax:505-508-5428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335G00000XSuppliersMedical Foods Supplier