1255425633 NPI number — THERESE HIDALGO CFNP

Table of content: THERESE HIDALGO CFNP (NPI 1255425633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255425633 NPI number — THERESE HIDALGO CFNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HIDALGO
Provider First Name:
THERESE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CFNP
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:
1255425633
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/06/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 26666
Provider Second Line Business Mailing Address:
PHS PROVIDER ENROLLMENT
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87125-6666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-923-5356
Provider Business Mailing Address Fax Number:
505-923-5354

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1619 W. DELGADO
Provider Second Line Business Practice Location Address:
BELEN HIGH SCHOOL-BASED HEALTH CENTER
Provider Business Practice Location Address City Name:
BELEN
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-966-1381
Provider Business Practice Location Address Fax Number:
505-966-1385
Provider Enumeration Date:
10/03/2006

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: 207Q00000X , with the licence number:  R18189 , 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: 000L6495 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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