1972634962 NPI number — ALVERA R UPSHAW LADAC

Table of content: ALVERA R UPSHAW LADAC (NPI 1972634962)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972634962 NPI number — ALVERA R UPSHAW LADAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
UPSHAW
Provider First Name:
ALVERA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LADAC
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:
1972634962
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:
1901 REDROCK DR
Provider Second Line Business Mailing Address:
PFS DEPT
Provider Business Mailing Address City Name:
GALLUP
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87301-5683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-863-7000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
650 VANDEN BOSCH PKWY
Provider Second Line Business Practice Location Address:
# B
Provider Business Practice Location Address City Name:
GALLUP
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87301-5508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-726-6900
Provider Business Practice Location Address Fax Number:
505-722-6192
Provider Enumeration Date:
03/08/2007

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: 101YA0400X , with the licence number:  3525 , 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: VNM00011BLC . This is a "VALUE OPTIONS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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