1801988266 NPI number — HORIZONS WEST MEDICAL GROUP A PROFESSIONAL CORPORTION

Table of content: (NPI 1801988266)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801988266 NPI number — HORIZONS WEST MEDICAL GROUP A PROFESSIONAL CORPORTION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HORIZONS WEST MEDICAL GROUP A PROFESSIONAL CORPORTION
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:
1801988266
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3911 AVENUE B
Provider Second Line Business Mailing Address:
SUITE 2100
Provider Business Mailing Address City Name:
SCOTTSBLUFF
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
69361
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-630-2131
Provider Business Mailing Address Fax Number:
308-630-1890

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3911 AVENUE B
Provider Second Line Business Practice Location Address:
SUITE 2100
Provider Business Practice Location Address City Name:
SCOTTSBLUFF
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
69361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-630-2131
Provider Business Practice Location Address Fax Number:
308-630-1890
Provider Enumeration Date:
09/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BJORLING
Authorized Official First Name:
VINCENT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
308-630-2100

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: CD2704 . This is a "PALMENTO GBA-RR MEDICARE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 283821 . This is a "MEDICARE OSCAR/CERTIFICAT" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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