1548633563 NPI number — CHARTER HEALTHCARE OF ALBUQUERQUE, LLC

Table of content: (NPI 1548633563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548633563 NPI number — CHARTER HEALTHCARE OF ALBUQUERQUE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARTER HEALTHCARE OF ALBUQUERQUE, 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:
1548633563
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12126 HWY 14 N STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDAR CREST
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87008-9406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-286-4219
Provider Business Mailing Address Fax Number:
505-286-7735

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12126 HWY 14 N STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CEDAR CREST
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87008-9406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-286-4219
Provider Business Practice Location Address Fax Number:
505-286-7735
Provider Enumeration Date:
11/12/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BOAL
Authorized Official First Name:
SYLVIE
Authorized Official Middle Name:
Authorized Official Title or Position:
COMPLIANCE OFFICER
Authorized Official Telephone Number:
909-644-4964

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  3547 , 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)





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