Provider Demographics
NPI:1134611460
Name:NICHOLAS L HUGENTOBLER PC
Entity type:Organization
Organization Name:NICHOLAS L HUGENTOBLER PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-453-1105
Mailing Address - Street 1:575 RIVERGATE UNIT 105
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7490
Mailing Address - Country:US
Mailing Address - Phone:970-259-3154
Mailing Address - Fax:970-828-1666
Practice Address - Street 1:2019 GALISTEO ST STE K-2
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-395-9575
Practice Address - Fax:505-466-5166
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NICHOLAS L HUGENTOBLER, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM18-00150244332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM60583517Medicaid