1750386405 NPI number — JACQUELYN LOUISE LARDIE NP

Table of content: JACQUELYN LOUISE LARDIE NP (NPI 1750386405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750386405 NPI number — JACQUELYN LOUISE LARDIE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARDIE
Provider First Name:
JACQUELYN
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

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:
1750386405
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
612 N. MAPLE STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARLSBAD
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-628-0927
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2420 W. PIERCE ST
Provider Second Line Business Practice Location Address:
STE. 103
Provider Business Practice Location Address City Name:
CARLSBAD
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-628-5051
Provider Business Practice Location Address Fax Number:
575-628-0493
Provider Enumeration Date:
06/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  4704242886 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: CNP-01544 , 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: 01500759 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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