1699346916 NPI number — MR. JODY CHRISTOPHER GONZALES CSW

Table of content: MR. JODY CHRISTOPHER GONZALES CSW (NPI 1699346916)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699346916 NPI number — MR. JODY CHRISTOPHER GONZALES CSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALES
Provider First Name:
JODY
Provider Middle Name:
CHRISTOPHER
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CSW
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:
1699346916
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 392
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCUMCARI
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88401-0392
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-461-9907
Provider Business Mailing Address Fax Number:
575-403-9867

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
419 S 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCUMCARI
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88401-2859
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-461-9907
Provider Business Practice Location Address Fax Number:
575-403-9867
Provider Enumeration Date:
07/07/2021

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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