1649834904 NPI number — MEDERI LIFE LLC

Table of content: (NPI 1649834904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649834904 NPI number — MEDERI LIFE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDERI LIFE LLC
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:
1649834904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6200 COORS BLVD NW STE A8
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:
87120-2794
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-433-4007
Provider Business Mailing Address Fax Number:
505-433-4068

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6200 COORS BLVD NW STE A8
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:
87120-2794
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-433-4007
Provider Business Practice Location Address Fax Number:
505-433-4068
Provider Enumeration Date:
04/23/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PADILLA
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
505-385-9060

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1649834904 . This is a "GROUP NPI" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 21089248 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".