1619150463 NPI number — SANTA MARIA EL MIRADOR

Table of content: (NPI 1619150463)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619150463 NPI number — SANTA MARIA EL MIRADOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANTA MARIA EL MIRADOR
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:
1619150463
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2041 S PACHECO ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
SANTA FE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87505-5473
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-424-7700
Provider Business Mailing Address Fax Number:
505-424-7707

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2041 S PACHECO ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87505-5473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-424-7700
Provider Business Practice Location Address Fax Number:
505-424-7707
Provider Enumeration Date:
12/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DURAN
Authorized Official First Name:
ELOY
Authorized Official Middle Name:
F
Authorized Official Title or Position:
DEPUTY DIRECTOR OF FINANCE
Authorized Official Telephone Number:
505-428-2004

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X , with the licence number:  02347611007 , 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: 60205512 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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