Provider Demographics
NPI:1063531341
Name:VILLAGE OF EAGLE NEST
Entity type:Organization
Organization Name:VILLAGE OF EAGLE NEST
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-376-2939
Mailing Address - Street 1:74 TOMBOY DR.
Mailing Address - Street 2:
Mailing Address - City:EAGLE NEST
Mailing Address - State:NM
Mailing Address - Zip Code:87718
Mailing Address - Country:US
Mailing Address - Phone:505-377-0663
Mailing Address - Fax:
Practice Address - Street 1:74 TOMBOY DR.
Practice Address - Street 2:
Practice Address - City:EAGLE NEST
Practice Address - State:NM
Practice Address - Zip Code:87718
Practice Address - Country:US
Practice Address - Phone:505-377-0663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE VILLAGE OF EAGLE NEST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-28
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR0837Medicaid
NMR0837Medicaid