1750498002 NPI number — SHIRLEE SUE SEATON P.T.

Table of content: SHIRLEE SUE SEATON P.T. (NPI 1750498002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750498002 NPI number — SHIRLEE SUE SEATON P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEATON
Provider First Name:
SHIRLEE
Provider Middle Name:
SUE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1750498002
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1612 S MAIN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTALES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88130-7331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-356-1631
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1429 S AVENUE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTALES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88130-6837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-356-4888
Provider Business Practice Location Address Fax Number:
505-359-3108
Provider Enumeration Date:
08/24/2006

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: 225100000X , with the licence number:  1377 , 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: PROVP16520 . This is a "MOLINA ID" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 2387 . This is a "LOVELACE ID" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 006 . This is a "HCH ID" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NM00Q005 . This is a "BLUE CROSS ID" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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