Provider Demographics
NPI:1053458240
Name:MOMS LLC
Entity type:Organization
Organization Name:MOMS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:K
Authorized Official - Last Name:SPELLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-751-5714
Mailing Address - Street 1:1329 GUSDORF RD
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6282
Mailing Address - Country:US
Mailing Address - Phone:575-737-6504
Mailing Address - Fax:575-737-6504
Practice Address - Street 1:1329 GUSDORF RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6282
Practice Address - Country:US
Practice Address - Phone:575-737-6504
Practice Address - Fax:575-737-6504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6432261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM300521152Medicare PIN