1336228519 NPI number — DR. GEORGIA ROSALIE GRAHAM DR OF CHIROPRACTIC

Table of content: DR. GEORGIA ROSALIE GRAHAM DR OF CHIROPRACTIC (NPI 1336228519)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336228519 NPI number — DR. GEORGIA ROSALIE GRAHAM DR OF CHIROPRACTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
GEORGIA
Provider Middle Name:
ROSALIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DR OF CHIROPRACTIC
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:
1336228519
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1330 SAN PEDRO NE
Provider Second Line Business Mailing Address:
#101
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-265-4697
Provider Business Mailing Address Fax Number:
505-265-0840

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1330 SAN PEDRO NE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-265-4697
Provider Business Practice Location Address Fax Number:
505-265-0846
Provider Enumeration Date:
11/06/2006

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: 111N00000X , with the licence number:  876 , 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: K486 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 663252 . This is a "ACN UNITED" identifier . This identifiers is of the category "OTHER".




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