Provider Demographics
NPI:1811300619
Name:DONA ANA MEDICAL SUPPLY
Entity type:Organization
Organization Name:DONA ANA MEDICAL SUPPLY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RRT
Authorized Official - Phone:575-257-7174
Mailing Address - Street 1:116 NOB HILL DR
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-6044
Mailing Address - Country:US
Mailing Address - Phone:575-257-7174
Mailing Address - Fax:575-257-5362
Practice Address - Street 1:116 NOB HILL DR
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6044
Practice Address - Country:US
Practice Address - Phone:575-257-7174
Practice Address - Fax:575-257-5362
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DONA ANA MEDIAL SUPPLY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM57976332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM65801571Medicaid
NM4805110001Medicare NSC