1982730669 NPI number — STATE OF NEW MEXICO

Table of content: (NPI 1982730669)

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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