1598866808 NPI number — INDUSTRIAL REHABILITATION CLINIC, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598866808 NPI number — INDUSTRIAL REHABILITATION CLINIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDUSTRIAL REHABILITATION CLINIC, PC
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:
1598866808
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 91270
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:
87199-1270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-797-7691
Provider Business Mailing Address Fax Number:
505-797-7686

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5110 SAN FRANCISCO RD NE
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:
87109-4640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-797-7691
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REEVE
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
P
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
505-797-7691

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , 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)





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