1568776730 NPI number — ELIZABETH M TUCKER DO PC

Table of content: (NPI 1568776730)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568776730 NPI number — ELIZABETH M TUCKER DO PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELIZABETH M TUCKER DO PC
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:
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:
1568776730
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 W BOUTZ RD
Provider Second Line Business Mailing Address:
BLDG 1
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88005-3259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-532-7000
Provider Business Mailing Address Fax Number:
575-532-7006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1212 9TH ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ALAMOGORDO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88310-5842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-439-9997
Provider Business Practice Location Address Fax Number:
575-439-8080
Provider Enumeration Date:
07/30/2010

Additional Information

Authorized Official

Authorized Official Last Name:
TUCKER
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
575-921-5452

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  A-1455-08 , 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: 08929238 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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