Basic Information
| Provider Information | |||||||||
| NPI: | 1871826040 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIRANDA | ||||||||
| FirstName: | ADRIAN | ||||||||
| MiddleName: | G | ||||||||
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| NameSuffix: | |||||||||
| Credential: | BMS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 W. 21ST | ||||||||
| Address2: | |||||||||
| City: | CLOVIS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757692345 | ||||||||
| FaxNumber: | 5757699013 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 EAST FIRST | ||||||||
| Address2: | |||||||||
| City: | PORTALES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753591221 | ||||||||
| FaxNumber: | 5753591075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2009 | ||||||||
| LastUpdateDate: | 09/09/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.