Provider Demographics
NPI:1275716425
Name:FIRST MOUNTAIN STAR INJURY CLINIC
Entity Type:Organization
Organization Name:FIRST MOUNTAIN STAR INJURY CLINIC
Other - Org Name:MOUNTAIN STAR INJURY CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ART
Authorized Official - Middle Name:
Authorized Official - Last Name:ARCHULETA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:915-781-7827
Mailing Address - Street 1:5630 GATEWAY BLVD E
Mailing Address - Street 2:STE. 5-E
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-1748
Mailing Address - Country:US
Mailing Address - Phone:915-781-7827
Mailing Address - Fax:915-781-0884
Practice Address - Street 1:5630 GATEWAY BLVD E
Practice Address - Street 2:STE. 5-E
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-1748
Practice Address - Country:US
Practice Address - Phone:915-781-7827
Practice Address - Fax:915-781-0884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9245111N00000X
TX4847111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty