1194908277 NPI number — GRASSHOPPER NATURAL MEDICINE

Table of content: (NPI 1194908277)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194908277 NPI number — GRASSHOPPER NATURAL MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRASSHOPPER NATURAL MEDICINE
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:
MOUNTAIN SPIRIT INTEGRATIVE MEDICINE
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:
1194908277
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6628
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:
87197
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-501-2701
Provider Business Mailing Address Fax Number:
505-986-6005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
303 PASEO DE PERALTA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87501-1860
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-988-2449
Provider Business Practice Location Address Fax Number:
505-986-6005
Provider Enumeration Date:
12/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VIVIAN
Authorized Official First Name:
DAWN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
505-988-2449

Provider Taxonomy Codes

  • Taxonomy code: 171100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NM00RK09 . This is a "BCBS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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