1780629063 NPI number — JOAN BRUMAGE LISW

Table of content: JOAN BRUMAGE LISW (NPI 1780629063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780629063 NPI number — JOAN BRUMAGE LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUMAGE
Provider First Name:
JOAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LISW
Provider Gender Code:
F

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:
1780629063
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1330
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORMAN
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73070-1330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-307-6630
Provider Business Mailing Address Fax Number:
405-307-6660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1213 MICHIGAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALAMOGORDO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88310-6725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-921-1616
Provider Business Practice Location Address Fax Number:
575-434-3253
Provider Enumeration Date:
06/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  I05349 , 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)

  • Identifier: 67659721 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com