1447583836 NPI number — SUSAN'S LEGACY

Table of content: (NPI 1447583836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447583836 NPI number — SUSAN'S LEGACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUSAN'S LEGACY
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:
1447583836
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11005 SPAIN NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-843-8450
Provider Business Mailing Address Fax Number:
505-843-8449

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8100 MOUNTAIN RD NE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-843-8450
Provider Business Practice Location Address Fax Number:
505-840-8449
Provider Enumeration Date:
09/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WEIL
Authorized Official First Name:
KATHRYN
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
505-843-8450

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  251B00000X , 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: NM600724 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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