1114920717 NPI number — SAN MIGUEL CLINIC CORP

Table of content: (NPI 1114920717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114920717 NPI number — SAN MIGUEL CLINIC CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN MIGUEL CLINIC CORP
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:
1114920717
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5009
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37024-5009
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:
108 LEGION DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87701-4898
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-454-9499
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FEY
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
DIRECTOR REVENUE CYCLE
Authorized Official Telephone Number:
615-221-3641

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 47485817 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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