Healthcare Provider Details

I. General information

NPI: 1881908457
Provider Name (Legal Business Name): GANG RISK INTERVENTION PROJECT, INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2010
Last Update Date: 08/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 E 12TH ST
SILVER CITY NM
88061-6408
US

IV. Provider business mailing address

212 E 12TH ST
SILVER CITY NM
88061-6408
US

V. Phone/Fax

Practice location:
  • Phone: 575-388-2443
  • Fax:
Mailing address:
  • Phone: 575-388-2443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. KEVIN BENNETT FAST SR.
Title or Position: PRESIDENT
Credential:
Phone: 575-534-2020