1306824164 NPI number — LORRAINE L GARDNER P.T.

Table of content: LORRAINE L GARDNER P.T. (NPI 1306824164)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306824164 NPI number — LORRAINE L GARDNER P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDNER
Provider First Name:
LORRAINE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

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:
1306824164
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 TRINITY DR
Provider Second Line Business Mailing Address:
STE. N
Provider Business Mailing Address City Name:
LOS ALAMOS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87544-4102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-661-6191
Provider Business Mailing Address Fax Number:
505-663-0386

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2101 TRINITY DR
Provider Second Line Business Practice Location Address:
STE. N
Provider Business Practice Location Address City Name:
LOS ALAMOS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87544-4102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-661-6191
Provider Business Practice Location Address Fax Number:
505-663-0386
Provider Enumeration Date:
01/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  445 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2251E1200X , with the licence number: 445 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251H1200X , with the licence number: 445 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251H1300X , with the licence number: 445 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251N0400X , with the licence number: 445 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251P0200X , with the licence number: 445 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251S0007X , with the licence number: 445 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251X0800X , with the licence number: 445 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 850448868 . This is a "ALL OTHER INSURANCIES" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 201079804 . This is a "PRESBYTERIAN HEALTH PLAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 00074136 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: NM00Q036 . This is a "BLUECROSSBLUESHIELDS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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