1073605549 NPI number — INDUSTRIAL REHABILITATION CLINICS, PC

Table of content: (NPI 1073605549)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073605549 NPI number — INDUSTRIAL REHABILITATION CLINICS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDUSTRIAL REHABILITATION CLINICS, PC
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:
IRC ROSWELL
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:
1073605549
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
311 W COUNTRY CLUB RD
Provider Second Line Business Mailing Address:
#1
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88201-5839
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-622-6365
Provider Business Mailing Address Fax Number:
505-627-0730

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
311 W COUNTRY CLUB RD
Provider Second Line Business Practice Location Address:
#1
Provider Business Practice Location Address City Name:
ROSWELL
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88201-5839
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-622-6365
Provider Business Practice Location Address Fax Number:
505-627-0730
Provider Enumeration Date:
09/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REEVE
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
P
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
50579776914

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , 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)





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