Healthcare Provider Details

I. General information

NPI: 1700054772
Provider Name (Legal Business Name): SOUTHWEST ALTERNATIVE MEDICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523-A SOUTH CAMINO DEL RIO
DURANGO CO
81303
US

IV. Provider business mailing address

PO BOX 1211
BAYFIELD CO
81122-1211
US

V. Phone/Fax

Practice location:
  • Phone: 970-259-1450
  • Fax: 970-259-1471
Mailing address:
  • Phone: 970-259-1450
  • Fax: 970-259-1471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number1963
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR-40091
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number5468
License Number StateCO

VIII. Authorized Official

Name: DANIEL J. MCCLURE
Title or Position: OWNER
Credential: DC,CCSP
Phone: 970-259-1450