1164029252 NPI number — CYNTHIA (CINDY) M MARTIN RN

Table of content: CYNTHIA (CINDY) M MARTIN RN (NPI 1164029252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164029252 NPI number — CYNTHIA (CINDY) M MARTIN RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
CYNTHIA (CINDY)
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
F

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:
1164029252
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
EXCEPTIONAL PROGRAM OFFICE, 1118 W. AZTEC BLVD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AZTEC
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-334-3695
Provider Business Mailing Address Fax Number:
505-599-4388

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 RIO PECOS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AZTEC
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87410-1646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-334-2621
Provider Business Practice Location Address Fax Number:
505-599-4391
Provider Enumeration Date:
10/02/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  R34985 , 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: 1919 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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