1275174658 NPI number — SM GANTZ OT SERVICES

Table of content: (NPI 1275174658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275174658 NPI number — SM GANTZ OT SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SM GANTZ OT SERVICES
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:
6
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:
1275174658
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 13907
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88013-3907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-288-1969
Provider Business Mailing Address Fax Number:
575-532-9539

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1485 N MAIN ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88001-1182
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-288-1969
Provider Business Practice Location Address Fax Number:
575-532-9539
Provider Enumeration Date:
10/07/2019

Additional Information

Authorized Official

Authorized Official Last Name:
GANTZ
Authorized Official First Name:
BRYAN
Authorized Official Middle Name:
KEITH
Authorized Official Title or Position:
GUARDIAN/OWNER
Authorized Official Telephone Number:
575-312-0120

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0000082220 . This is a "NATIONAL CERTIFIED GUARDIAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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