Provider Demographics
NPI:1386630242
Name:VILLAGE OF CAUSEY
Entity Type:Organization
Organization Name:VILLAGE OF CAUSEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMS CAPTAIN
Authorized Official - Prefix:
Authorized Official - First Name:T.
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:EMT-I
Authorized Official - Phone:505-273-4249
Mailing Address - Street 1:116 MAIN ST
Mailing Address - Street 2:BOX 79
Mailing Address - City:CAUSEY
Mailing Address - State:NM
Mailing Address - Zip Code:88113-9717
Mailing Address - Country:US
Mailing Address - Phone:505-273-4249
Mailing Address - Fax:505-273-4248
Practice Address - Street 1:116 MAIN ST
Practice Address - Street 2:BOX 79
Practice Address - City:CAUSEY
Practice Address - State:NM
Practice Address - Zip Code:88113-9717
Practice Address - Country:US
Practice Address - Phone:505-273-4249
Practice Address - Fax:505-273-4248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0323312146M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, IntermediateGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR2916Medicaid
NM=========Medicare PIN