Provider Demographics
NPI:1275539504
Name:BLUE HORSESHOE, INC.
Entity Type:Organization
Organization Name:BLUE HORSESHOE, INC.
Other - Org Name:ADVANCED HOME CARE AND MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRENT
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:BATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-627-6256
Mailing Address - Street 1:315 W COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5892
Mailing Address - Country:US
Mailing Address - Phone:505-627-6256
Mailing Address - Fax:
Practice Address - Street 1:315 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5892
Practice Address - Country:US
Practice Address - Phone:505-627-6256
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6632251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN3288Medicaid
NMN3288Medicaid