1912922808 NPI number — OLGA M. SACASA P.T.

Table of content: TYLER R WANKE (NPI 1255894234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912922808 NPI number — OLGA M. SACASA P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SACASA
Provider First Name:
OLGA
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

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:
1912922808
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
535 US HIGHWAY 314, SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS LUNAS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-861-1200
Provider Business Mailing Address Fax Number:
505-861-1220

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
535 US HIGHWAY 314, SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS LUNAS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-861-1200
Provider Business Practice Location Address Fax Number:
505-861-1220
Provider Enumeration Date:
07/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2549 , 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: 82487022 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000Q0406 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1356491146 . This is a "BELEN FACILITY NPI" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 1386651412 . This is a "LOS LUNAS FACILITY NPI" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 1245380039 . This is a "BERNALILLO FACILITY NPI" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 2549 . This is a "NM STATE LICENSE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: P00348973 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".