1467850214 NPI number — TRACEY RIVERA

Table of content: TRACEY RIVERA (NPI 1467850214)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467850214 NPI number — TRACEY RIVERA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVERA
Provider First Name:
TRACEY
Provider Middle Name:
Provider Name Prefix Text:
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:
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:
1467850214
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 W GRIGGS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88001-1234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-647-2800
Provider Business Mailing Address Fax Number:
575-647-2898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2211 N VALLEY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88007-5160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-527-7911
Provider Business Practice Location Address Fax Number:
575-527-4287
Provider Enumeration Date:
12/10/2014

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: 171M00000X , 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: 18677037 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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