Provider Demographics
NPI:1538770698
Name:DR JEDD RANEY PEDIATRICS LLC
Entity type:Organization
Organization Name:DR JEDD RANEY PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:JEDD
Authorized Official - Last Name:RANEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:575-887-0530
Mailing Address - Street 1:2402 W PIERCE ST STE 3C
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-3564
Mailing Address - Country:US
Mailing Address - Phone:575-887-0530
Mailing Address - Fax:575-885-6309
Practice Address - Street 1:2402 W PIERCE ST STE 3C
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3564
Practice Address - Country:US
Practice Address - Phone:575-887-0530
Practice Address - Fax:575-885-6309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM12138720Medicaid
NM1265660633OtherNPI