1659689347 NPI number — TAOS SPORTS MEDICINE SERICES LLC

Table of content: (NPI 1659689347)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659689347 NPI number — TAOS SPORTS MEDICINE SERICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAOS SPORTS MEDICINE SERICES LLC
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:
1659689347
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1398 WEIMER RD
Provider Second Line Business Mailing Address:
STE 203
Provider Business Mailing Address City Name:
TAOS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87571-6397
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-737-0304
Provider Business Mailing Address Fax Number:
575-737-0383

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12 CRESTVIEW DRIVE
Provider Second Line Business Practice Location Address:
STE 1S
Provider Business Practice Location Address City Name:
ANGEL FIRE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87710-0489
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-377-1900
Provider Business Practice Location Address Fax Number:
575-377-2383
Provider Enumeration Date:
09/16/2010

Additional Information

Authorized Official

Authorized Official Last Name:
LUCERO
Authorized Official First Name:
JOCELYN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
575-737-0304

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  3072B1 , 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: 43383386 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 700521047 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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