Provider Demographics
NPI:1225297500
Name:DONA ANA MEDICAL SUPPLY
Entity Type:Organization
Organization Name:DONA ANA MEDICAL SUPPLY
Other - Org Name:SILVER CITY MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REG RESP THERAPIST / OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RRT
Authorized Official - Phone:575-644-2701
Mailing Address - Street 1:3851 E LOHMAN AVE
Mailing Address - Street 2:SUITE #4
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8296
Mailing Address - Country:US
Mailing Address - Phone:575-388-1574
Mailing Address - Fax:575-534-4701
Practice Address - Street 1:3175 N LESLIE RD
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-7211
Practice Address - Country:US
Practice Address - Phone:575-388-1574
Practice Address - Fax:575-522-5938
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DONA ANA MEDICAL SUPPLY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-03
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1110332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM65801571Medicaid
NM02946075001OtherNEW MEXICO STATE TAX ID
NM02946075001OtherNEW MEXICO STATE TAX ID