Provider Demographics
NPI:1093071987
Name:TASKER HATCH ROWAN LLC
Entity Type:Organization
Organization Name:TASKER HATCH ROWAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EBONIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-850-3769
Mailing Address - Street 1:8201 GOLF COURSE RD NW STE C3
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-5805
Mailing Address - Country:US
Mailing Address - Phone:505-892-9010
Mailing Address - Fax:505-899-4804
Practice Address - Street 1:106 MAIN ST NE
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7559
Practice Address - Country:US
Practice Address - Phone:505-865-1999
Practice Address - Fax:505-899-4804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2829122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM22535268Medicaid