Healthcare Provider Details

I. General information

NPI: 1659624211
Provider Name (Legal Business Name): ALFRED CHAVEZ JR. LBSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 CENTRAL AVE
BAYARD NM
88023
US

IV. Provider business mailing address

PO BOX 1000
BAYARD NM
88023-1000
US

V. Phone/Fax

Practice location:
  • Phone: 575-537-4000
  • Fax:
Mailing address:
  • Phone: 575-537-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number050566935
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: