1356407027 NPI number — HIGH DESERT FOOT & ANKLE SPECIALISTS, LLC

Table of content: (NPI 1356407027)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356407027 NPI number — HIGH DESERT FOOT & ANKLE SPECIALISTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HIGH DESERT FOOT & ANKLE SPECIALISTS, 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:
1356407027
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 53056
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:
87153-3056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-565-1155
Provider Business Mailing Address Fax Number:
505-565-1166

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9412 INDIAN SCHOOL RD NE
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:
87112-2878
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-565-1155
Provider Business Practice Location Address Fax Number:
505-565-1166
Provider Enumeration Date:
12/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROE
Authorized Official First Name:
TOMMY
Authorized Official Middle Name:
GENE
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
505-565-1155

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  279 , 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: 55003800 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 84001780 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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