1902000680 NPI number — DANIEL JUNCK LLC

Table of content: (NPI 1902000680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902000680 NPI number — DANIEL JUNCK LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DANIEL JUNCK 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:
1902000680
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
223 N GUADALUPE ST
Provider Second Line Business Mailing Address:
SUITE 466
Provider Business Mailing Address City Name:
SANTA FE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87501-1868
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-670-6549
Provider Business Mailing Address Fax Number:
505-830-4803

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
223 N GUADALUPE ST
Provider Second Line Business Practice Location Address:
SUITE 466
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87501-1868
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-670-6549
Provider Business Practice Location Address Fax Number:
505-830-4803
Provider Enumeration Date:
06/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JUNCK
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
PHYSICIAN, OWNER
Authorized Official Telephone Number:
505-670-6549

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  2005-0474 , 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: 46257268 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com