1497814693 NPI number — DEBORAH STUBBLEFIELD

Table of content: (NPI 1497814693)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497814693 NPI number — DEBORAH STUBBLEFIELD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEBORAH STUBBLEFIELD
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:
1497814693
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1309
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRUTH OR CONSEQUENCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87901-1309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-894-6640
Provider Business Mailing Address Fax Number:
505-894-9482

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
612 N DATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRUTH OR CONSEQUENCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87901-1742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-894-6640
Provider Business Practice Location Address Fax Number:
505-894-9482
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STUBBLEFIELD
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
505-894-6640

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  210 , 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: 29126771 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: NM00TB63 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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