Healthcare Provider Details

I. General information

NPI: 1053054932
Provider Name (Legal Business Name): TIMMY RAY BAILEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 BECKER AVE
BELEN NM
87002-3634
US

IV. Provider business mailing address

1894 CHAPARRAL LOOP
SOCORRO NM
87801-3718
US

V. Phone/Fax

Practice location:
  • Phone: 505-864-8998
  • Fax: 505-864-8888
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: