1770048092 NPI number — DEZI GOLDEN THERAPIES, LLC

Table of content: (NPI 1770048092)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770048092 NPI number — DEZI GOLDEN THERAPIES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEZI GOLDEN THERAPIES, 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:
1770048092
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4310 CANTERRA ARC
Provider Second Line Business Mailing Address:
DBA/DEZI GOLDEN THERAPIES, LLC
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88011-1805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-932-9741
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4310 CANTERRA ARC
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88011-1805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-932-9741
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/01/2019

Additional Information

Authorized Official

Authorized Official Last Name:
GOLDEN
Authorized Official First Name:
DESIREE
Authorized Official Middle Name:
Authorized Official Title or Position:
LIC MED MSSG THERAPIST/LIFE COACH
Authorized Official Telephone Number:
575-932-9741

Provider Taxonomy Codes

  • Taxonomy code: 106S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111NR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 172M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 172P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 172V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 173C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 175F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081P2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2083P0901X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 221700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 302R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 405300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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