1174678817 NPI number — MS. KATHLEEN MARTINA MADRID L. M.T. #505

Table of content: MS. KATHLEEN MARTINA MADRID L. M.T. #505 (NPI 1174678817)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174678817 NPI number — MS. KATHLEEN MARTINA MADRID L. M.T. #505

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MADRID
Provider First Name:
KATHLEEN
Provider Middle Name:
MARTINA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
L. M.T. #505
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:
1174678817
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 414
Provider Second Line Business Mailing Address:
HCR 77 BOX F9
Provider Business Mailing Address City Name:
OJO CALIENTE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87549-0414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-747-9798
Provider Business Mailing Address Fax Number:
505-747-9798

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1167A HIGHWAY 554
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL RITO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87530-0805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-581-0033
Provider Business Practice Location Address Fax Number:
505-581-0034
Provider Enumeration Date:
01/24/2007

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: 174400000X , with the licence number:  L.M.T. #505 , 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)





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