1790802890 NPI number — TAOS PICURIS HEALTH CENTER

Table of content: (NPI 1790802890)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790802890 NPI number — TAOS PICURIS HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAOS PICURIS HEALTH CENTER
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:
TAOS PICURIS HEALTH CENTER PHARMACY
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:
1790802890
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 95452
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44101-0033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-758-6995
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1090 GOAT SPRINGS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAOS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-758-6995
Provider Business Practice Location Address Fax Number:
505-751-5211
Provider Enumeration Date:
03/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CUMMINGS
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY PROGRAM SPECIALIST
Authorized Official Telephone Number:
405-951-6086

Provider Taxonomy Codes

  • Taxonomy code: 332800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2058715 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: B4347 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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