1437420791 NPI number — MS. CARLA DIANA CHAVEZ

Table of content: MS. CARLA DIANA CHAVEZ (NPI 1437420791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437420791 NPI number — MS. CARLA DIANA CHAVEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAVEZ
Provider First Name:
CARLA
Provider Middle Name:
DIANA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHAVEZ-TRUJILLO
Provider Other First Name:
CARLA
Provider Other Middle Name:
DIANA
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1437420791
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 NATIONAL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87701-4319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-690-1171
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
706 KANE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87701-4949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-690-1171
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/18/2012

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101Y00000X , with the licence number: 0096141 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 33786569 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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