1255896353 NPI number — 32 DEGREES GENUINE, LLC

Table of content: (NPI 1255896353)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255896353 NPI number — 32 DEGREES GENUINE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
32 DEGREES GENUINE, 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:
1255896353
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5701 CARMEL AVE NE STE B
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:
87113-2843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-595-6622
Provider Business Mailing Address Fax Number:
505-514-0754

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5701 CARMEL AVE NE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87113-2843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-308-5226
Provider Business Practice Location Address Fax Number:
505-514-0754
Provider Enumeration Date:
02/04/2019

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
THERAPIST/OWNER
Authorized Official Telephone Number:
505-595-6622

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 63238730 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com