1740376292 NPI number — NEW MEXICO CONSUMER DIRECT PERSONAL CARE, LLC

Table of content: (NPI 1740376292)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740376292 NPI number — NEW MEXICO CONSUMER DIRECT PERSONAL CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW MEXICO CONSUMER DIRECT PERSONAL CARE, 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:
CONSUMER DIRECT CARE NETWORK NEW MEXICO
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:
1740376292
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 CONSUMER DIRECT WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISSOULA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59808-5037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-532-1900
Provider Business Mailing Address Fax Number:
406-532-1901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 PENNSYLVANIA ST 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:
87110-7408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-884-3116
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLEDSOE
Authorized Official First Name:
BEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
406-532-1900

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 84385359 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01926250 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 22554254 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 55821065 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57575533 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com