1487754735 NPI number — HIGH DESERT NEUROLOGY

Table of content: (NPI 1487754735)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487754735 NPI number — HIGH DESERT NEUROLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HIGH DESERT NEUROLOGY
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:
1487754735
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 44430
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIO RANCHO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87174-4430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-892-8915
Provider Business Mailing Address Fax Number:
505-994-3028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4131 BARBARA LOOP SE
Provider Second Line Business Practice Location Address:
SUITE 1-A
Provider Business Practice Location Address City Name:
RIO RANCHO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87124-1362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-892-8915
Provider Business Practice Location Address Fax Number:
505-994-3028
Provider Enumeration Date:
09/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRINCIPAL
Authorized Official Telephone Number:
505-892-8915

Provider Taxonomy Codes

  • Taxonomy code: 2084N0402X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 201047864 . This is a "PHP & SALUD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 23432 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00NM009T07 . This is a "BCBS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: C100521093 . This is a "UNITED AMERICAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NM9999 . This is a "MUTUAL OF OMAHA" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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