1649414699 NPI number — SMALL EPIPHANIES, INC.

Table of content: (NPI 1649414699)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649414699 NPI number — SMALL EPIPHANIES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMALL EPIPHANIES, INC.
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:
1649414699
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 533
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AZTEC
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87410-0533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-334-4919
Provider Business Mailing Address Fax Number:
505-335-4916

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 S MAIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AZTEC
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87410-2121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-334-4919
Provider Business Practice Location Address Fax Number:
505-334-4916
Provider Enumeration Date:
04/21/2009

Additional Information

Authorized Official

Authorized Official Last Name:
OLSON
Authorized Official First Name:
JOSEPHINE
Authorized Official Middle Name:
SNYDER
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
505-334-4919

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  0213 , 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: N4017 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0213 . This is a "NM STATE THERAPY LICENSE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 1528256351 . This is a "INDIVIDUAL NPI NUMBER" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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