Basic Information
| Provider Information | |||||||||
| NPI: | 1275719866 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVORE | ||||||||
| FirstName: | JOHNNY | ||||||||
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| Mailing Information | |||||||||
| Address1: | EXIT 102 OFF I - 40 1/2 MI SOUTH | ||||||||
| Address2: | PO BOX 130 | ||||||||
| City: | SAN FIDEL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870490130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055525385 | ||||||||
| FaxNumber: | 5055525473 | ||||||||
| Practice Location | |||||||||
| Address1: | EXIT 102 OFF I - 40 1/2 MI SOUTH | ||||||||
| Address2: | |||||||||
| City: | SAN FIDEL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870490130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055525385 | ||||||||
| FaxNumber: | 5055525473 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2008 | ||||||||
| LastUpdateDate: | 01/14/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146L00000X | 00015585 | NM | Y | Emergency Medical Service Providers | Emergency Medical Technician, Paramedic |
No ID Information.