1700492600 NPI number — GLOW WOMEN'S HEALTH, LLC

Table of content: (NPI 1700492600)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700492600 NPI number — GLOW WOMEN'S HEALTH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLOW WOMEN'S HEALTH, 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:
GLOW WOMEN'S HEALTH
Provider Other Organization Name Type Code:
3
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:
1700492600
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1118 DESERT SAGE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOBBS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88242-9787
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-577-1617
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5419 N LOVINGTON HWY STE 10
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOBBS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88240-9135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-577-1617
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/17/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
FRANCINE
Authorized Official Middle Name:
NICOLE
Authorized Official Title or Position:
NP/OWNER
Authorized Official Telephone Number:
806-577-1617

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 61585335 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".