Healthcare Provider Details

I. General information

NPI: 1386630242
Provider Name (Legal Business Name): VILLAGE OF CAUSEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 MAIN ST BOX 79
CAUSEY NM
88113-9717
US

IV. Provider business mailing address

116 MAIN ST BOX 79
CAUSEY NM
88113-9717
US

V. Phone/Fax

Practice location:
  • Phone: 505-273-4249
  • Fax: 505-273-4248
Mailing address:
  • Phone: 505-273-4249
  • Fax: 505-273-4248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146M00000X
TaxonomyIntermediate Emergency Medical Technician
License Number0323312
License Number StateNM

VIII. Authorized Official

Name: T. ANN CLARK
Title or Position: EMS CAPTAIN
Credential: EMT-I
Phone: 505-273-4249