MAIN STREET MEDICAL CENTER LLC NPI 1225389919

NPI Information

NPI: 1225389919
Provider Name: MAIN STREET MEDICAL CENTER, LLC
Classification: Nurse Practitioner - 363LF0000X
Entity Type: Organization

Specialization: Family

CLIA Number: 32D2048486

Address:
200 PIONEER RD
STE A
RED RIVER, NM
ZIP 87558
Phone: (575) 754-6330
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MAIN STREET MEDICAL CENTER, LLC is a family nurse practitioner in Red River, NM. MAIN STREET MEDICAL CENTER, LLC NPI is 1225389919. The provider is registered as an organization entity type.

The provider's business location address is:

200 PIONEER RD
STE A
RED RIVER, NM
ZIP 87558-010
Phone: (575) 754-6330
Fax: (575) 754-6232

The provider's authorized official is Jessica L Cross .
The authorized official title is Owner and has the following contact phone number (575) 754-6330.

The CLIA number assigned to this NPI record is 32D2048486 - practitioner other with a certificate type of Certificate of Waiver.

The enumeration date for this NPI number is 9/21/2012 and was last updated on 3/4/2024.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No.	Taxonomy Code	Taxonomy Clasification	Taxonomy Specialization	License Number	License State	Primary
1	261QP2300X	Clinic/Center	Primary Care			No
2	363LF0000X	Nurse Practitioner	Family	CNP-01822	NEW MEXICO	Yes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No.	Other Provider Identifier	Other Provider Identifier Type	Other Provider Identifier State	Other Provider Identifier Issuer
1	1225389919	OTHER	NEW MEXICO	ORG 2 NPI

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 5/5/2024

NPI Synchronization or Removal

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