1548358583 NPI number — MRS. BONNIE BOUCHER

Table of content: MRS. BONNIE BOUCHER (NPI 1548358583)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548358583 NPI number — MRS. BONNIE BOUCHER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUCHER
Provider First Name:
BONNIE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
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:
DIETZ
Provider Other First Name:
BONNIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1548358583
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11068
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:
87192-0068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-620-9785
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10801 LOMAS BLVD NE STE 105
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:
87112-5474
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-620-9785
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/11/2006

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: 101YM0800X , with the licence number:  0065142 , 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: 12349 . This is a "LOVELACE HEALTH PLAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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