1073853271 NPI number — AMISTAD MILESTONES, LLC

Table of content: (NPI 1477820496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073853271 NPI number — AMISTAD MILESTONES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMISTAD MILESTONES, 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:
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:
1073853271
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1090
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88004-1090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-523-2288
Provider Business Mailing Address Fax Number:
575-523-2299

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3050 N ROADRUNNER PKWY
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88011-0833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-523-2288
Provider Business Practice Location Address Fax Number:
575-523-2299
Provider Enumeration Date:
02/25/2013

Additional Information

Authorized Official

Authorized Official Last Name:
MORALES
Authorized Official First Name:
RICK
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
703-906-1613

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  I-06859 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 252Y00000X , with the licence number: I-06859 , 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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