1396705687 NPI number — RIO WEST MEDICAL, LLC

Table of content: SHARON BOONE M.D. (NPI 1023054160)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396705687 NPI number — RIO WEST MEDICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIO WEST MEDICAL, 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:
ROADRUNNER FOOTWEAR AND FOOTCARE
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:
1396705687
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 44787
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIO RANCHO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87174-4787
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-896-0533
Provider Business Mailing Address Fax Number:
505-896-0522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6200 COORS BLVD NW
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:
87120-2785
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-896-0533
Provider Business Practice Location Address Fax Number:
505-896-0522
Provider Enumeration Date:
03/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
YAUK
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
505-896-0533

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 06587577 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06928773 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 202003149 . This is a "PRESBYTERIAN NM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NM01TA20 . This is a "BCBSNM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 201065393 . This is a "PRESBYTERIAN NM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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