1205068236 NPI number — GEORGE HIGGINS FAMILY PRACTICE LLC

Table of content: (NPI 1205068236)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205068236 NPI number — GEORGE HIGGINS FAMILY PRACTICE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGE HIGGINS FAMILY PRACTICE LLC
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:
HIGGINS FAMILY PRACTICE
Provider Other Organization Name Type Code:
3
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:
1205068236
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 ENCINO PL NE
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87102-2619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-314-3142
Provider Business Mailing Address Fax Number:
888-874-3330

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
711 ENCINO PL NE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87102-2619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-314-3142
Provider Business Practice Location Address Fax Number:
888-874-3330
Provider Enumeration Date:
08/08/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HIGGINS
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
505-314-3142

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  86-245 , 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: 38950 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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