1700054772 NPI number — SOUTHWEST ALTERNATIVE MEDICAL, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700054772 NPI number — SOUTHWEST ALTERNATIVE MEDICAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST ALTERNATIVE MEDICAL, 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:
1700054772
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1211
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAYFIELD
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81122-1211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-259-1450
Provider Business Mailing Address Fax Number:
970-259-1471

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
523-A SOUTH CAMINO DEL RIO
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DURANGO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-259-1450
Provider Business Practice Location Address Fax Number:
970-259-1471
Provider Enumeration Date:
02/13/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCCLURE
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
970-259-1450

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  DR-40091 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2100X , with the licence number: 5468 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111NS0005X , with the licence number: 1963 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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