1467668814 NPI number — PROFESSIONAL COUNSELING ASSOCIATES OF NEW MEXICO

Table of content: (NPI 1467668814)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467668814 NPI number — PROFESSIONAL COUNSELING ASSOCIATES OF NEW MEXICO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL COUNSELING ASSOCIATES OF NEW MEXICO
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:
1467668814
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
419 S 2ND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCUMCARI
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88401-2859
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-461-3572
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
419 S 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCUMCARI
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88401-2859
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-461-3572
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MOYA
Authorized Official First Name:
RALPH
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
505-461-3572

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  LISW1041C0700X , 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: NM000217 . This is a "VALUE OPTIONS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 000A3588 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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