1245711662 NPI number — RISE SPEECH-LANGUAGE PATHOLOGY SERVICES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245711662 NPI number — RISE SPEECH-LANGUAGE PATHOLOGY SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RISE SPEECH-LANGUAGE PATHOLOGY SERVICES, 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:
1245711662
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 CALLEJA MIRAMONTE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAMY
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87540-9662
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-919-8149
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1012 MARQUEZ PL STE 211
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87505-1834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-302-0095
Provider Business Practice Location Address Fax Number:
855-729-9346
Provider Enumeration Date:
08/23/2018

Additional Information

Authorized Official

Authorized Official Last Name:
GARCIA
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
SLP/OWNER
Authorized Official Telephone Number:
505-302-0095

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP4932 , 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: 41432771 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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