1003827650 NPI number — PREMIER CARE LAS CRUCES

Table of content: (NPI 1003827650)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003827650 NPI number — PREMIER CARE LAS CRUCES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER CARE LAS CRUCES
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:
1003827650
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SULLIVAN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63080-0220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
STEFAN C SCHAEFER MD
Provider Second Line Business Practice Location Address:
2465 S TELSHOR BLVD
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-556-0101
Provider Business Practice Location Address Fax Number:
505-522-0808
Provider Enumeration Date:
08/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FEESE
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
573-860-2273

Provider Taxonomy Codes

  • Taxonomy code: 332900000X , with the licence number:  CL00010409 , 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: 3211327 . This is a "OTHER ID NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3211327 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 85804762 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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