Healthcare Provider Details

I. General information

NPI: 1992684146
Provider Name (Legal Business Name): NOVA CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2025
Last Update Date: 09/01/2025
Certification Date: 09/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 ANTHONY DR STE H
ANTHONY NM
88021-9379
US

IV. Provider business mailing address

5203 JUAN TABO BLVD NE STE 2B
ALBUQUERQUE NM
87111-2691
US

V. Phone/Fax

Practice location:
  • Phone: 575-517-3885
  • Fax:
Mailing address:
  • Phone: 214-790-6829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KRISTAN VALDES
Title or Position: OWNER
Credential: NURSE PRACTITIONER
Phone: 214-790-6829