1093034928 NPI number — COUNTY OF ROOSEVELT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093034928 NPI number — COUNTY OF ROOSEVELT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF ROOSEVELT
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:
1093034928
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 641880
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68164-7880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-572-4019
Provider Business Mailing Address Fax Number:
402-572-4019

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1578 NEW MEXICO 88
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTALES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88130-9669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-276-8484
Provider Business Practice Location Address Fax Number:
575-356-8307
Provider Enumeration Date:
05/17/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HAMILTON
Authorized Official First Name:
AMBER
Authorized Official Middle Name:
S
Authorized Official Title or Position:
COUNTY MANAGER
Authorized Official Telephone Number:
575-356-5307

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  52863 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3416L0300X , with the licence number: 52863 , 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)