Basic Information
| Provider Information | |||||||||
| NPI: | 1982995205 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KOLOMEIR CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8205 SPAIN RD NE | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871093155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053847352 | ||||||||
| FaxNumber: | 5052747338 | ||||||||
| Practice Location | |||||||||
| Address1: | 5345 WYOMING BLVD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871093193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058566898 | ||||||||
| FaxNumber: | 5052921574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2011 | ||||||||
| LastUpdateDate: | 01/28/2014 | ||||||||
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| AuthorizedOfficialLastName: | KOLOMEIR | ||||||||
| AuthorizedOfficialFirstName: | MAUREEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | NURSE PRACTITIONER OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5057203819 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PMHNP-BC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 84887231 | 05 | NM | MEDICAID |