1386933620 NPI number — A CENTER FOR FUNCTION AND CREATIVITY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386933620 NPI number — A CENTER FOR FUNCTION AND CREATIVITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
A CENTER FOR FUNCTION AND CREATIVITY
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:
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:
1386933620
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10701 CORRALES BLVD NW
Provider Second Line Business Mailing Address:
SUITE 17
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87114-1087
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10701 CORRALES BLVD NW
Provider Second Line Business Practice Location Address:
SUITE 17
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87114-1087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-890-0868
Provider Business Practice Location Address Fax Number:
505-898-0169
Provider Enumeration Date:
04/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HOBBS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
505-890-0868

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X , with the licence number:  75988721 , 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: 75988721 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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