1912950999 NPI number — KENNETH W HODDER LISW

Table of content: KENNETH W HODDER LISW (NPI 1912950999)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912950999 NPI number — KENNETH W HODDER LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HODDER
Provider First Name:
KENNETH
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LISW
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:
1912950999
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 ALAMEDA BLVD NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87114-1937
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-897-7883
Provider Business Mailing Address Fax Number:
505-792-8578

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 ALAMEDA BLVD NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87114-1937
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-897-7883
Provider Business Practice Location Address Fax Number:
505-792-8578
Provider Enumeration Date:
05/18/2006

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: 104100000X , with the licence number:  I-2148 , 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: 105879 . This is a "MHN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 860663612 0001 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 86066361287114A001 . This is a "TRIWEST HEALTHCARE ALLIAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NM10005 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00NM00R32L . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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