Healthcare Provider Details

I. General information

NPI: 1538199773
Provider Name (Legal Business Name): COUNTY LINE MEDICAL SERVICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 12/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 S COUNTY LINE DR SPC A
CHAPARRAL NM
88081-7802
US

IV. Provider business mailing address

545 S COUNTY LINE DR SPC A
CHAPARRAL NM
88081-7802
US

V. Phone/Fax

Practice location:
  • Phone: 575-824-5007
  • Fax:
Mailing address:
  • Phone: 575-824-5007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KYONG YOL KO
Title or Position: MD / PRESIDENT
Credential: MD
Phone: 575-824-5007