1023151966 NPI number — RIO PECOS MEDICAL ASSOCIATES LTD

Table of content: (NPI 1023151966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023151966 NPI number — RIO PECOS MEDICAL ASSOCIATES LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIO PECOS MEDICAL ASSOCIATES LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023151966
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2608
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88202-2608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-622-6322
Provider Business Mailing Address Fax Number:
575-622-6888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 W COUNTRY CLUB RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSWELL
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88201-5892
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-622-6322
Provider Business Practice Location Address Fax Number:
575-622-6888
Provider Enumeration Date:
02/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DODSON
Authorized Official First Name:
CODY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
575-622-6322

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 55526721 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com