1871726174 NPI number — CHARLES HERBERT

Table of content: CHARLES HERBERT (NPI 1871726174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871726174 NPI number — CHARLES HERBERT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERBERT
Provider First Name:
CHARLES
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1871726174
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
535 HWY 314 SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS LUNAS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87031-9600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-866-0055
Provider Business Mailing Address Fax Number:
505-866-0057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
180 E HIGHWAY 550
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
BERNALILLO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87004-5967
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-771-2447
Provider Business Practice Location Address Fax Number:
505-771-2360
Provider Enumeration Date:
09/02/2009

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: 225100000X , with the licence number:  3741 , 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: 1245380039 . This is a "BERNALILLO FACILITY NPI" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 1386651412 . This is a "BILLING NPI" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 000Q0406 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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