1548452949 NPI number — TRUST IN GOD REHABILITATION

Table of content: (NPI 1548452949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548452949 NPI number — TRUST IN GOD REHABILITATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRUST IN GOD REHABILITATION
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:
1548452949
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 6499
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAOS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-758-3879
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
489 BLUEBERRY HILL ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL PRADO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-758-3879
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/10/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GONZALES
Authorized Official First Name:
FRED
Authorized Official Middle Name:
Authorized Official Title or Position:
BOARD PRESIDENT
Authorized Official Telephone Number:
575-758-3879

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  M06217 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 324500000X , with the licence number: CU00010276 , 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)