Provider Demographics
NPI:1891874319
Name:PORTALES HOME MEDICAL EQUIPMENT INC
Entity Type:Organization
Organization Name:PORTALES HOME MEDICAL EQUIPMENT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:NUCKOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-356-0688
Mailing Address - Street 1:312 S. MAIN
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-0600
Mailing Address - Country:US
Mailing Address - Phone:575-356-0688
Mailing Address - Fax:
Practice Address - Street 1:312 S. MAIN
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-5917
Practice Address - Country:US
Practice Address - Phone:575-356-0688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM332B00000X332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMS8459Medicaid
NMNMT28FOtherBCBS
NMS8459Medicaid