1437170404 NPI number — MJRX V, LLC

Table of content: (NPI 1437170404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437170404 NPI number — MJRX V, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MJRX V, LLC
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:
1437170404
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7209 JEFFERSON ST 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:
87109-4307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-881-4601
Provider Business Mailing Address Fax Number:
505-881-4647

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2402 W PIERCE ST
Provider Second Line Business Practice Location Address:
STE 2B
Provider Business Practice Location Address City Name:
CARLSBAD
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88220-3537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-885-2979
Provider Business Practice Location Address Fax Number:
575-885-2979
Provider Enumeration Date:
07/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KOCHERHANS
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER/CEO
Authorized Official Telephone Number:
505-881-4601

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: PH00002988 , 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: 55533 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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