1780686907 NPI number — ZUNI MEDICAL SUPPLY ENTERPRISE

Table of content: (NPI 1780686907)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780686907 NPI number — ZUNI MEDICAL SUPPLY ENTERPRISE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ZUNI MEDICAL SUPPLY ENTERPRISE
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:
1780686907
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 339
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ZUNI
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87327-0339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-782-2434
Provider Business Mailing Address Fax Number:
505-782-2457

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BUILDING 52 ROUTE 301 NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ZUNI
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87327-0339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-782-2434
Provider Business Practice Location Address Fax Number:
505-782-2457
Provider Enumeration Date:
06/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
QUETAWKI
Authorized Official First Name:
ARLEN
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
GOV./PRES. BOARD OF DIRECTORS
Authorized Official Telephone Number:
505-782-2434

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  01103 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BX2000X , with the licence number: 01103 , 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: T1046 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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