1932267259 NPI number — PUEBLO OF LAGUNA

Table of content: (NPI 1932267259)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932267259 NPI number — PUEBLO OF LAGUNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUEBLO OF LAGUNA
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:
6
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:
1932267259
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 179
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAGUNA
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87026-0179
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-552-5796
Provider Business Mailing Address Fax Number:
505-552-6941

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 BLUE STAR LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARAJE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-552-1102
Provider Business Practice Location Address Fax Number:
505-552-6577
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KING
Authorized Official First Name:
MILES
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
505-552-5779

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  54194 , 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: 10014280 . This is a "LOVELACE SALUD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 00NM00RC01 . This is a "BCBS OF NM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 964678 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201078520 . This is a "PRESBYTERIAN HEALTH PLAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: R0225 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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