1841287182 NPI number — MISS CAROL JEAN SHOULDERS RD CDE LD

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 1841287182 NPI number — MISS CAROL JEAN SHOULDERS RD CDE LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHOULDERS
Provider First Name:
CAROL
Provider Middle Name:
JEAN
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
RD CDE LD
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:
1841287182
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 160
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHIPROCK
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87420-0160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-368-8020
Provider Business Mailing Address Fax Number:
505-368-6431

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
US HWY 491 NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHIPROCK
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-968-6020
Provider Business Practice Location Address Fax Number:
505-368-6481
Provider Enumeration Date:
10/03/2005

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: 133V00000X , with the licence number:  505 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 163WD0400X , with the licence number: 09315463 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 17125758 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".