Basic Information
| Provider Information | |||||||||
| NPI: | 1992812069 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SANDIA OXYGEN LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4431 ANAHEIM AVE NE STE A | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871131580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058832817 | ||||||||
| FaxNumber: | 5057978539 | ||||||||
| Practice Location | |||||||||
| Address1: | 4431 ANAHEIM AVE NE STE A | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058832817 | ||||||||
| FaxNumber: | 5057978539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 05/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | WEAVER | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5058832817 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 54328713 | 05 | NM | MEDICAID |