1619277910 NPI number — SHIPROCK CLINIC LTD

Table of content: (NPI 1619277910)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619277910 NPI number — SHIPROCK CLINIC LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHIPROCK CLINIC LTD
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:
1619277910
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1709
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHIPROCK
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87420-1709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-368-4568
Provider Business Mailing Address Fax Number:
505-368-4502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HWY 491 SUITE 6
Provider Second Line Business Practice Location Address:
SHIPROCK SHOPPING CENTER
Provider Business Practice Location Address City Name:
SHIPROCK
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-368-4568
Provider Business Practice Location Address Fax Number:
505-368-4502
Provider Enumeration Date:
11/02/2010

Additional Information

Authorized Official

Authorized Official Last Name:
VANBUSKIRK
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
505-368-4568

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1002 , 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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