1679651319 NPI number — CLOVIS HOMECARE, INC.

Table of content: (NPI 1679651319)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679651319 NPI number — CLOVIS HOMECARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLOVIS HOMECARE, 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:
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:
1679651319
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1944 W 21ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLOVIS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88101-4026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-769-2243
Provider Business Mailing Address Fax Number:
575-762-6452

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1944 W 21ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLOVIS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88101-4026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-769-2243
Provider Business Practice Location Address Fax Number:
575-762-6452
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CORBIN
Authorized Official First Name:
AMY
Authorized Official Middle Name:
MICHELLE
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
575-769-2243

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  6398 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3747P1801X , with the licence number: 6398 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: N2725 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: Z7511 . This is a "STATE PCO PROGRAM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: Z7511 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: D0214 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: D0214 . This is a "STATE WAIVER PROGRAM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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