1306810692 NPI number — LOS ALAMOS NM ENDOSCOPY ASC LLC

Table of content: (NPI 1306810692)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306810692 NPI number — LOS ALAMOS NM ENDOSCOPY ASC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOS ALAMOS NM ENDOSCOPY ASC 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:
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:
1306810692
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1911 CENTRAL AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
LOS ALAMOS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87544-3023
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-661-9976
Provider Business Mailing Address Fax Number:
505-661-2604

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1911 CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LOS ALAMOS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87544-3023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-661-9976
Provider Business Practice Location Address Fax Number:
505-661-2604
Provider Enumeration Date:
02/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOLDEN
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHIEF MANAGER OF LLC
Authorized Official Telephone Number:
615-665-1283

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  3201 , 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: 98128361 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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