Basic Information
| Provider Information | |||||||||
| NPI: | 1447317243 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRUJILLO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 CEDAR ST SE STE 6600 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871065411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057244300 | ||||||||
| FaxNumber: | 5057244384 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 CEDAR ST SE STE 6600 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871065411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057244300 | ||||||||
| FaxNumber: | 5057244384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 07/16/2013 | ||||||||
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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 | 246Z00000X | N | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | 246ZS0410X | Y |
ID Information
| ID | Type | State | Issuer | Description | 89709 | 01 | CST CERTIFICATE NO | OTHER |