1568866085 NPI number — RE-CYCLED MAN LLC

Table of content: (NPI 1568866085)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568866085 NPI number — RE-CYCLED MAN LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RE-CYCLED MAN 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:
A NEW AWAKENING RIO RANCHO
Provider Other Organization Name Type Code:
3
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:
1568866085
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
412 ASBURY RD NE
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
RIO RANCHO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87124-5627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-489-4935
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1207 GOLF COURSE RD SE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
RIO RANCHO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87124-1999
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-994-4100
Provider Business Practice Location Address Fax Number:
505-994-1229
Provider Enumeration Date:
10/13/2014

Additional Information

Authorized Official

Authorized Official Last Name:
PACHECO
Authorized Official First Name:
ERICK
Authorized Official Middle Name:
BRIAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
505-489-4935

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 93588755 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 32D2113373 . This is a "CLINICAL LABORATORY IMPROVMENT AMENDMENTS CERTIFICATE OF WAIVER" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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