Healthcare Provider Details

I. General information

NPI: 1093935355
Provider Name (Legal Business Name): UNION COUNTY MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2007
Last Update Date: 07/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 N. 3RD AVE
CLAYTON NM
88415-0565
US

IV. Provider business mailing address

314 N. 3RD AVE
CLAYTON NM
88415-0565
US

V. Phone/Fax

Practice location:
  • Phone: 575-374-8313
  • Fax: 575-374-2064
Mailing address:
  • Phone: 575-374-8313
  • Fax: 575-374-2064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6239
License Number StateNM

VIII. Authorized Official

Name: MRS. LORI VAN WORMER
Title or Position: PRESIDENT
Credential:
Phone: 575-374-8313