1801100466 NPI number — BERNALILLO FAMILY HEALTH CLINIC, LLC

Table of content: (NPI 1801100466)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801100466 NPI number — BERNALILLO FAMILY HEALTH CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BERNALILLO FAMILY HEALTH CLINIC, 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:
OAK STREET CLINIC
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:
1801100466
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25744
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87125-0744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-508-0197
Provider Business Mailing Address Fax Number:
505-508-0465

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 OAK ST NE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87106-4740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-508-0197
Provider Business Practice Location Address Fax Number:
505-508-0465
Provider Enumeration Date:
08/05/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DELUISA
Authorized Official First Name:
JASON
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
505-331-0295

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  CNP-01518 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: Q7732 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 21253790 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 77304853 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10326855 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 37805771 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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