1790918175 NPI number — MR. THEODORE DAVID HURSH JR.

Table of content: MR. THEODORE DAVID HURSH JR. (NPI 1790918175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790918175 NPI number — MR. THEODORE DAVID HURSH JR.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HURSH
Provider First Name:
THEODORE
Provider Middle Name:
DAVID
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
Provider Gender Code:
M

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:
1790918175
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 W GRIGGS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88001-1234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-647-2800
Provider Business Mailing Address Fax Number:
575-647-2898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 E. 10TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALAMOGORDO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-439-2824
Provider Business Practice Location Address Fax Number:
575-439-2861
Provider Enumeration Date:
09/01/2009

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 18677037 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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