Basic Information
| Provider Information | |||||||||
| NPI: | 1164456208 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PINO | ||||||||
| FirstName: | EUNICE | ||||||||
| MiddleName: | BACA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PINO | ||||||||
| OtherFirstName: | EUNICE | ||||||||
| OtherMiddleName: | BACA | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNM | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6320 RIVERSIDE PLAZA LN NW | ||||||||
| Address2: | STE B | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871201710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058436168 | ||||||||
| FaxNumber: | 5052479743 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 HOSPITAL LOOP NE STE 105 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871092100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058436168 | ||||||||
| FaxNumber: | 5057921978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 07/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | 487 | NM | Y | Other Service Providers | Midwife |
ID Information
| ID | Type | State | Issuer | Description | 70478741 | 05 | NM | MEDICAID |