1508832791 NPI number — MRS. KRISTINE S WILLIAMS RD LD

Table of content: MRS. KRISTINE S WILLIAMS RD LD (NPI 1508832791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508832791 NPI number — MRS. KRISTINE S WILLIAMS RD LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIAMS
Provider First Name:
KRISTINE
Provider Middle Name:
S
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD LD
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:
1508832791
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43 OPHIR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DURANGO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-382-0927
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12000 STONE LAKE RD
Provider Second Line Business Practice Location Address:
DULCE HEALTH CENTER
Provider Business Practice Location Address City Name:
DULCE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-759-3291
Provider Business Practice Location Address Fax Number:
505-759-7289
Provider Enumeration Date:
02/27/2006

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: 133V00000X , with the licence number:  468 , 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: 000K3526 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: HSZ196 . This is a "MEDICARE PART B" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 56186878 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com