1285754465 NPI number — JOSE MARIO LEON-FRIAS

Table of content: (NPI 1285754465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285754465 NPI number — JOSE MARIO LEON-FRIAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOSE MARIO LEON-FRIAS
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:
1285754465
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 2722
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NOGALES
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85628-2722
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
644-414-5533
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
AV. LOPEZ MATEOS 171-2
Provider Second Line Business Practice Location Address:
PLAZA AZTECA
Provider Business Practice Location Address City Name:
NOGALES
Provider Business Practice Location Address State Name:
SONORA
Provider Business Practice Location Address Postal Code:
84000
Provider Business Practice Location Address Country Code:
MX
Provider Business Practice Location Address Telephone Number:
631-312-5544
Provider Business Practice Location Address Fax Number:
631-312-5545
Provider Enumeration Date:
03/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LEON-FRIAS
Authorized Official First Name:
JOSE
Authorized Official Middle Name:
MARIO
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
644-414-5533

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MXN-0000070 . This is a "SOUTHWEST SERVICE INC." identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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