1316016769 NPI number — PHC-LAS CRUCES INC

Table of content: (NPI 1316016769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316016769 NPI number — PHC-LAS CRUCES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHC-LAS CRUCES 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:
1316016769
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 SEVEN SPRINGS WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-4536
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-920-7000
Provider Business Mailing Address Fax Number:
615-920-8913

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1705 E UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88001-5780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-556-6500
Provider Business Practice Location Address Fax Number:
575-522-4168
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DILLON
Authorized Official First Name:
TERRANCE
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT SECRETARY
Authorized Official Telephone Number:
502-596-7220

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  3172 , 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: 201060532 . This is a "PRESBYTERIAN HEALTH" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 98921576 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: NM01HH76 . This is a "BDBS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: PROVA21336 . This is a "MOLINA HEALTHCARE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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