1033135074 NPI number — STATE OF NEW MEXICO

Table of content: (NPI 1033135074)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033135074 NPI number — STATE OF NEW MEXICO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF NEW MEXICO
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:
Provider Other Organization Name Type Code:
6
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:
1033135074
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
992 S BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRUTH OR CONSEQUENCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-894-4200
Provider Business Mailing Address Fax Number:
575-894-4291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
992 S BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRUTH OR CONSEQUENCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-894-4200
Provider Business Practice Location Address Fax Number:
575-894-4291
Provider Enumeration Date:
07/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RICHTER
Authorized Official First Name:
MARIE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
ADMINISTRATIVE SERVICES DIRECTOR
Authorized Official Telephone Number:
575-894-4216

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  CS00021264 , 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: 65755 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3208774 . This is a "MEDICARE D" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com