1104378314 NPI number — DESERT MOUNTAIN SKIN CANCER SURGERY, LLC

Table of content: (NPI 1104378314)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104378314 NPI number — DESERT MOUNTAIN SKIN CANCER SURGERY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESERT MOUNTAIN SKIN CANCER SURGERY, LLC
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:
1104378314
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 604
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLACITAS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87043-0604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-980-8738
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2019 GALISTEO STREET
Provider Second Line Business Practice Location Address:
SUITE N-9B
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-980-8738
Provider Business Practice Location Address Fax Number:
505-404-8423
Provider Enumeration Date:
11/04/2016

Additional Information

Authorized Official

Authorized Official Last Name:
REISINGER
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
505-980-8738

Provider Taxonomy Codes

  • Taxonomy code: 207ND0101X , with the licence number:  MD2011-0829 , 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: 1003975699 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com