Provider Demographics
NPI:1124579958
Name:BLUE AND RED BIRD CORPORATION, PC.
Entity Type:Organization
Organization Name:BLUE AND RED BIRD CORPORATION, PC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALI
Authorized Official - Middle Name:M
Authorized Official - Last Name:GHAFFARI
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:575-762-6492
Mailing Address - Street 1:815 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-5514
Mailing Address - Country:US
Mailing Address - Phone:575-762-6492
Mailing Address - Fax:757-935-8333
Practice Address - Street 1:815 W 14TH ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-5514
Practice Address - Country:US
Practice Address - Phone:575-762-6492
Practice Address - Fax:757-935-8333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81202261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMCN7783Medicare UPIN