1700362738 NPI number — FOUR CORNERS LLC

Table of content: (NPI 1700362738)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700362738 NPI number — FOUR CORNERS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUR CORNERS 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:
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:
1700362738
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5761 W PARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHANDLER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85226-1241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-339-9726
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1704 LLANO ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87505-5415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-339-9276
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/12/2018

Additional Information

Authorized Official

Authorized Official Last Name:
WALI
Authorized Official First Name:
OSAMA
Authorized Official Middle Name:
Authorized Official Title or Position:
GENERAL MANAGER
Authorized Official Telephone Number:
520-339-9726

Provider Taxonomy Codes

  • Taxonomy code: 172A00000X , 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: 5696496 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com