1295817906 NPI number — SMYRNA ENTERPRISES, INC

Table of content: (NPI 1295817906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295817906 NPI number — SMYRNA ENTERPRISES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMYRNA ENTERPRISES, INC
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:
1295817906
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
518 VALENCIA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87701-3716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-425-3880
Provider Business Mailing Address Fax Number:
505-425-2929

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
518 VALENCIA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87701-3716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-425-3880
Provider Business Practice Location Address Fax Number:
505-425-2929
Provider Enumeration Date:
10/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
JUSTIN
Authorized Official Middle Name:
O
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
505-425-3880

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  3221 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251G00000X , with the licence number: 3209 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251G00000X , with the licence number: 3211 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3211 . This is a "STATE LICENSE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 3221 . This is a "STATE LICENSE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 3209 . This is a "STATE LICENSE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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