1598797805 NPI number — LA CLINICA DEL PUEBLO DE RIO ARRIBA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598797805 NPI number — LA CLINICA DEL PUEBLO DE RIO ARRIBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LA CLINICA DEL PUEBLO DE RIO ARRIBA
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:
1598797805
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 250
Provider Second Line Business Mailing Address:
US HWY 84, COUNTY ROAD 0324, #14
Provider Business Mailing Address City Name:
TIERRA AMARILLA
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87575-0250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-588-7252
Provider Business Mailing Address Fax Number:
575-588-9132

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
US HWY 84, COUNTY ROAD 0324, #14
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIERRA AMARILLA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87575-0250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-588-7252
Provider Business Practice Location Address Fax Number:
575-588-9132
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HORAN
Authorized Official First Name:
LEONARD
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
575-588-7252

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000050740 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1891562674 . This is a "PHYSICAL THERAPIST" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 1215129291 . This is a "AMBULANCE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 00050740 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1467742015 . This is a "LUIGI A. DULANTO, M.D." identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 1366581373 . This is a "JODI K. CASADOS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 1730472085 . This is a "LEVI I. MAES, M.D." identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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