Provider Demographics
NPI:1144529694
Name:CLITEPIC LLC
Entity type:Organization
Organization Name:CLITEPIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUTE CARE NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:SOPHIA
Authorized Official - Middle Name:CHU
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, ACNP-C,FNP-C,
Authorized Official - Phone:505-401-0810
Mailing Address - Street 1:12231 ACADEMY RD NE
Mailing Address - Street 2:#301-223
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-7236
Mailing Address - Country:US
Mailing Address - Phone:505-792-6590
Mailing Address - Fax:505-858-1467
Practice Address - Street 1:700 HIGH ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2565
Practice Address - Country:US
Practice Address - Phone:505-401-0810
Practice Address - Fax:505-858-1467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-23
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP00285363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ5234Medicaid
NMQ5234Medicaid