1962743534 NPI number — DE BACA FAMILY PRACTICE CLINIC

Table of content: VIRGINIA ANN BYRD P.T. (NPI 1073575031)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962743534 NPI number — DE BACA FAMILY PRACTICE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DE BACA FAMILY PRACTICE CLINIC
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:
GUADALUPE FAMILY DENTAL
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:
1962743534
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 349
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT SUMNER
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88119-0349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-355-2414
Provider Business Mailing Address Fax Number:
575-355-7894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
552 US HWY 54
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-472-2414
Provider Business Practice Location Address Fax Number:
575-472-2416
Provider Enumeration Date:
03/07/2013

Additional Information

Authorized Official

Authorized Official Last Name:
WALRAVEN
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
575-355-2420

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 84331534 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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