Basic Information
| Provider Information | |||||||||
| NPI: | 1689096190 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINON PERINATAL | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3741 RUTLEDGE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057989300 | ||||||||
| FaxNumber: | 5057980808 | ||||||||
| Practice Location | |||||||||
| Address1: | 3741 RUTLEDGE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057989300 | ||||||||
| FaxNumber: | 5057980808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2014 | ||||||||
| LastUpdateDate: | 01/17/2014 | ||||||||
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| AuthorizedOfficialLastName: | HURLEY | ||||||||
| AuthorizedOfficialFirstName: | PEG | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5052638808 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PINON PERINATAL | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 170300000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Genetic Counselor, MS |
ID Information
| ID | Type | State | Issuer | Description | D6491 | 05 | NM | MEDICAID |