1376722827 NPI number — MEDICINE CLINIC LLC

Table of content: (NPI 1376722827)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376722827 NPI number — MEDICINE CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICINE CLINIC 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:
1376722827
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5419 N LOVINGTON HWY STE 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOBBS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88240-9135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-392-8943
Provider Business Mailing Address Fax Number:
505-392-8960

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5419 N LOVINGTON HWY STE 10
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOBBS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88240-9135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-392-8943
Provider Business Practice Location Address Fax Number:
505-392-8960
Provider Enumeration Date:
11/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FONSECA
Authorized Official First Name:
JESUS
Authorized Official Middle Name:
J
Authorized Official Title or Position:
INTERNAL MEDICINE
Authorized Official Telephone Number:
505-392-8943

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NM009390 . This is a "BCBS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com