1376829317 NPI number — MR. BORIS A. VALDEVIT L.P.C.C.

Table of content: RAVINDRA EDUPUGANTI M.D. (NPI 1689651770)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376829317 NPI number — MR. BORIS A. VALDEVIT L.P.C.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VALDEVIT
Provider First Name:
BORIS
Provider Middle Name:
A.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
L.P.C.C.
Provider Gender Code:
M

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:
1376829317
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
959 LUJAN HILL RD
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:
88007-6302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-635-0390
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2402 SOUTH LOCUST STREET
Provider Second Line Business Practice Location Address:
SUITE 5
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-521-4188
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/21/2011

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: 101YM0800X , with the licence number:  0794 , 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)





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