Healthcare Provider Details

I. General information

NPI: 1053535450
Provider Name (Legal Business Name): CITY OF MOUNTAINAIR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 ACOMA
MOUNTAINAIR NM
87036-0591
US

IV. Provider business mailing address

4501 OSUNA RD NE
ALBUQUERQUE NM
87109-4467
US

V. Phone/Fax

Practice location:
  • Phone: 505-847-2321
  • Fax: 505-847-0421
Mailing address:
  • Phone: 505-226-1800
  • Fax: 505-247-2482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number14303
License Number StateNM

VIII. Authorized Official

Name: MR. SAM E BLACKSHEAR
Title or Position: AMBULANCE CHIEF
Credential:
Phone: 505-847-2316