Provider Demographics
NPI:1750767810
Name:SOUTHWEST CARE CENTER JEFFERSON ALBUQUERQUE
Entity type:Organization
Organization Name:SOUTHWEST CARE CENTER JEFFERSON ALBUQUERQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-989-8200
Mailing Address - Street 1:PO BOX 6880
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-6880
Mailing Address - Country:US
Mailing Address - Phone:505-955-9454
Mailing Address - Fax:505-989-8131
Practice Address - Street 1:4710 JEFFERSON NE
Practice Address - Street 2:SUITE A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-955-9454
Practice Address - Fax:505-888-9644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-30
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM55202080Medicaid
NMK5766Medicaid