Provider Demographics
NPI:1053535450
Name:CITY OF MOUNTAINAIR
Entity type:Organization
Organization Name:CITY OF MOUNTAINAIR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AMBULANCE CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:BLACKSHEAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-847-2316
Mailing Address - Street 1:4501 OSUNA RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4467
Mailing Address - Country:US
Mailing Address - Phone:505-226-1800
Mailing Address - Fax:505-247-2482
Practice Address - Street 1:105 ACOMA
Practice Address - Street 2:
Practice Address - City:MOUNTAINAIR
Practice Address - State:NM
Practice Address - Zip Code:87036-0591
Practice Address - Country:US
Practice Address - Phone:505-847-2321
Practice Address - Fax:505-847-0421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM14303341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR2809Medicaid
NMR2809Medicare ID - Type Unspecified