Provider Demographics
NPI:1144334715
Name:STARGATE MOBILITY
Entity type:Organization
Organization Name:STARGATE MOBILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DODGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-208-0056
Mailing Address - Street 1:500 S SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-2866
Mailing Address - Country:US
Mailing Address - Phone:575-208-0056
Mailing Address - Fax:505-216-9380
Practice Address - Street 1:500 S SUNSET AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-2866
Practice Address - Country:US
Practice Address - Phone:575-208-0056
Practice Address - Fax:505-216-9380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM03065376002332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM42874360Medicaid
NM4202490002Medicare NSC