Provider Demographics
NPI:1417112178
Name:FOUR CORNERS NEPHROLOGY ASSOCIATES PC
Entity Type:Organization
Organization Name:FOUR CORNERS NEPHROLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BILLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:STOLWORTHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-326-6521
Mailing Address - Street 1:312 S LAKE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5620
Mailing Address - Country:US
Mailing Address - Phone:505-326-6521
Mailing Address - Fax:505-325-6699
Practice Address - Street 1:1902 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5021
Practice Address - Country:US
Practice Address - Phone:505-326-6521
Practice Address - Fax:505-325-6699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC263308Medicare PIN
AZZ23290Medicare PIN