1063428431 NPI number — MIMBRES HEALTH MAINTENANCE ASSOCIATES P C

Table of content: (NPI 1063428431)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063428431 NPI number — MIMBRES HEALTH MAINTENANCE ASSOCIATES P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIMBRES HEALTH MAINTENANCE ASSOCIATES P C
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:
1063428431
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
850 W. FLORIDA
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEMING
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-544-2800
Provider Business Mailing Address Fax Number:
505-544-2801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 W FLORIDA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEMING
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88030-4558
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-544-2800
Provider Business Practice Location Address Fax Number:
505-544-2801
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LAFON
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
505-544-2800

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  81-71 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2080N0001X , with the licence number: 2003-0634 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 26393 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47426781 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 48702 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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