1205917150 NPI number — MEDICAL IMAGING OF CARLSBAD PA

Table of content: DR. JOHN MARTIN QUILLIN PHD, MPH, MS, CGC (NPI 1568625135)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205917150 NPI number — MEDICAL IMAGING OF CARLSBAD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL IMAGING OF CARLSBAD PA
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:
1205917150
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
411 N CANYON
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARLSBAD
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-887-0323
Provider Business Mailing Address Fax Number:
575-887-8018

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
411 N CANYON
Provider Second Line Business Practice Location Address:
CARLSBAD MEDICAL CENTER
Provider Business Practice Location Address City Name:
CARLSBAD
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-887-0323
Provider Business Practice Location Address Fax Number:
575-887-8018
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SULLESTA
Authorized Official First Name:
LACHME
Authorized Official Middle Name:
T
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
575-887-0323

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 50872 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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