1407989718 NPI number — DAVID BRECK BOGGIO SW

Table of content: DAVID BRECK BOGGIO SW (NPI 1407989718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407989718 NPI number — DAVID BRECK BOGGIO SW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOGGIO
Provider First Name:
DAVID
Provider Middle Name:
BRECK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SW
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:
1407989718
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4717 HANNETT AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87110-5015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-514-8695
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PO BOX 3338
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87190-3338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-255-5099
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/14/2007

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: 1041S0200X , with the licence number:  Z 8589 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: I-4374 , 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: Z 8589 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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