Provider Demographics
NPI:1144468075
Name:SOUTHWEST MEDICAL CLINIC INC
Entity type:Organization
Organization Name:SOUTHWEST MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FATEMEH
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOORI
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:505-869-0300
Mailing Address - Street 1:2230 BOSQUE FARMS BLVD
Mailing Address - Street 2:
Mailing Address - City:BOSQUE FARMS
Mailing Address - State:NM
Mailing Address - Zip Code:87068-9334
Mailing Address - Country:US
Mailing Address - Phone:505-975-7269
Mailing Address - Fax:
Practice Address - Street 1:2230 BOSQUE FARMS BLVD
Practice Address - Street 2:
Practice Address - City:BOSQUE FARMS
Practice Address - State:NM
Practice Address - Zip Code:87068-9334
Practice Address - Country:US
Practice Address - Phone:505-869-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-30
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR37006363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM25079310Medicaid
NM349531402OtherMEDICARE
NMQ34901Medicare UPIN