1982814380 NPI number — MR. RAYMOND M KEESWOOD JR. LADAC

Table of content: MR. RAYMOND M KEESWOOD JR. LADAC (NPI 1982814380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982814380 NPI number — MR. RAYMOND M KEESWOOD JR. LADAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEESWOOD
Provider First Name:
RAYMOND
Provider Middle Name:
M
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
LADAC
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:
1982814380
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 873
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERFLOW
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87421-0873
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HWY 491 NORTH PINION STREET
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:
505-368-1438
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2007

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:  0073301 , 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)





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