Provider Demographics
NPI:1548472830
Name:BLUE AND RED BIRD CORP PC
Entity type:Organization
Organization Name:BLUE AND RED BIRD CORP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:M
Authorized Official - Last Name:GHAFFARI
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:505-762-6492
Mailing Address - Street 1:815 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-5514
Mailing Address - Country:US
Mailing Address - Phone:505-762-6492
Mailing Address - Fax:505-769-8236
Practice Address - Street 1:815 W 14TH ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-5514
Practice Address - Country:US
Practice Address - Phone:505-762-6492
Practice Address - Fax:505-769-8236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMS2511Medicaid
NM700521052Medicare ID - Type Unspecified
NMS2511Medicaid