Basic Information
| Provider Information | |||||||||
| NPI: | 1457636706 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALTEON HEALTH NEW MEXICO LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ISLAND MEDICAL LOE LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4535 DRESSLER RD NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447182545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309944409 | ||||||||
| FaxNumber: | 3304928489 | ||||||||
| Practice Location | |||||||||
| Address1: | 5419 N LOVINGTON HWY | ||||||||
| Address2: | |||||||||
| City: | HOBBS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882409100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2406862300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2011 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REESE | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8556870618 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 58674853 | 05 | NM | MEDICAID |