1225389919 NPI number — MAIN STREET MEDICAL CENTER, LLC

Table of content: (NPI 1225389919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225389919 NPI number — MAIN STREET MEDICAL CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAIN STREET MEDICAL 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:
1225389919
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RED RIVER
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87558-0010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-779-8015
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 PIONEER RD
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
RED RIVER
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87558-0010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-754-6330
Provider Business Practice Location Address Fax Number:
575-754-6232
Provider Enumeration Date:
09/21/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CROSS
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
575-754-6330

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: CNP-01822 , 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: 1225389919 . This is a "ORG 2 NPI" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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