1295780146 NPI number — PEAK MEDICAL LAS CRUCES NO. 2, LLC

Table of content: (NPI 1295780146)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295780146 NPI number — PEAK MEDICAL LAS CRUCES NO. 2, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEAK MEDICAL LAS CRUCES NO. 2, 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:
CASA DE ORO CENTER
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:
1295780146
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1005 LUJAN HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88007-6304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-523-4573
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 LUJAN HILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88007-6304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-523-4573
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BERG
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT SECRETARY
Authorized Official Telephone Number:
505-468-4752

Provider Taxonomy Codes

  • Taxonomy code: 311500000X , with the licence number:  1031 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 1031 , 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: 00NM01M532 . This is a "BC/BS OF NM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: PROVA41094 . This is a "MOLINA SALUD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 17214 . This is a "PRES SALUD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 10003570 . This is a "LOVELACE SALUD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 0586122 . This is a "CIGNA" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 59602295 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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