1639145808 NPI number — ALBUQUERQUE CENTER FOR RHEUMATOLOGY PC

Table of content: (NPI 1639145808)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639145808 NPI number — ALBUQUERQUE CENTER FOR RHEUMATOLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALBUQUERQUE CENTER FOR RHEUMATOLOGY 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:
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:
1639145808
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1617 UNIVERSITY BLVD NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87102-1710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-341-4148
Provider Business Mailing Address Fax Number:
505-345-9914

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1617 UNIVERSITY BLVD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87102-1710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-341-4148
Provider Business Practice Location Address Fax Number:
505-345-9914
Provider Enumeration Date:
02/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PACHECO
Authorized Official First Name:
LEROY
Authorized Official Middle Name:
ARNOLD
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
505-341-4148

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  94-116 , 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: 12375 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 522944752M . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".




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