Provider Demographics
NPI:1982995205
Name:KOLOMEIR CLINIC, LLC
Entity Type:Organization
Organization Name:KOLOMEIR CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLOMEIR
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:505-720-3819
Mailing Address - Street 1:8205 SPAIN RD NE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3155
Mailing Address - Country:US
Mailing Address - Phone:505-384-7352
Mailing Address - Fax:505-274-7338
Practice Address - Street 1:5345 WYOMING BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3193
Practice Address - Country:US
Practice Address - Phone:505-856-6898
Practice Address - Fax:505-292-1574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-20
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM84887231Medicaid
NM84887231Medicaid