Healthcare Provider Details

I. General information

NPI: 1205854494
Provider Name (Legal Business Name): BLUE HORSESHOE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W COUNTRY CLUB RD
ROSWELL NM
88201-5892
US

IV. Provider business mailing address

315 W COUNTRY CLUB RD
ROSWELL NM
88201-5892
US

V. Phone/Fax

Practice location:
  • Phone: 505-623-0799
  • Fax: 505-627-6257
Mailing address:
  • Phone: 505-623-0799
  • Fax: 505-627-6257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number0604031
License Number StateNM

VIII. Authorized Official

Name: JACKI GAYLE BATES
Title or Position: BILLING MANAGER
Credential:
Phone: 505-623-0799