1205878758 NPI number — ALBUQUERQUE AMBULATORY EYE SURGERY CENTER, LLC

Table of content: (NPI 1205878758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205878758 NPI number — ALBUQUERQUE AMBULATORY EYE SURGERY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALBUQUERQUE AMBULATORY EYE SURGERY CENTER, 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:
1205878758
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 90550
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87199-0550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-768-1333
Provider Business Mailing Address Fax Number:
505-244-9566

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5901 HARPER DR NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87109-3587
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-823-8545
Provider Business Practice Location Address Fax Number:
505-823-8549
Provider Enumeration Date:
06/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
JANICE
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
505-246-2622

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  3087 , 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: 154528701 . This is a "TEXAS MEDICAID" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 490005505 . This is a "RRB RAILROAD MEDICARE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 28957512 . This is a "COLORADO MEDICAID" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NM00SS87 . This is a "BCBSNM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 741597 . This is a "ARIZONA MEDICAID" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 34301364 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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