Healthcare Provider Details

I. General information

NPI: 1790918175
Provider Name (Legal Business Name): MR. THEODORE DAVID HURSH JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2009
Last Update Date: 02/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 E. 10TH STREET
ALAMOGORDO NM
88310
US

IV. Provider business mailing address

100 W GRIGGS AVE
LAS CRUCES NM
88001-1234
US

V. Phone/Fax

Practice location:
  • Phone: 575-439-2824
  • Fax: 575-439-2861
Mailing address:
  • Phone: 575-647-2800
  • Fax: 575-647-2898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: