1073825816 NPI number — JUAN TABO FAMILY MEDICINE PC

Table of content: (NPI 1073825816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073825816 NPI number — JUAN TABO FAMILY MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JUAN TABO FAMILY MEDICINE PC
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:
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:
1073825816
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3309 JUAN TABO BLVD NE
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87111-5131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-554-1786
Provider Business Mailing Address Fax Number:
505-508-2482

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3309 JUAN TABO BLVD NE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87111-5131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-554-1786
Provider Business Practice Location Address Fax Number:
505-508-2482
Provider Enumeration Date:
07/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MUNETA
Authorized Official First Name:
BEN
Authorized Official Middle Name:
Authorized Official Title or Position:
REGISTERED AGENT
Authorized Official Telephone Number:
505-554-1786

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  MD2007-0072 , 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: 1477790327 . This is a "CURRENT PROVIDER NUMBER" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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