1982730669 NPI number — STATE OF NEW MEXICO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982730669 NPI number — STATE OF NEW MEXICO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF NEW MEXICO
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:
1982730669
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
02/13/2017
NPI Reactivation Date:
02/22/2017

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 293
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA CLARA
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88026-0293
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-537-8600
Provider Business Mailing Address Fax Number:
575-537-3753

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
41 FORT BAYARD ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA CLARA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-537-8600
Provider Business Practice Location Address Fax Number:
575-537-8869
Provider Enumeration Date:
02/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BAYS
Authorized Official First Name:
SHERRI
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
575-537-8606

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 5011 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282E00000X , with the licence number: 5011 , 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: 014 . This is a "MOLINA HEALTHCARE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 51972786 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50716 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: NM00N526 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 3204574 . This is a "N.A.B.P. IDENTIFIER #" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: AL3362097 . This is a "D.E. A. IDENTIFIER NUMBER" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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