Healthcare Provider Details

I. General information

NPI: 1154554541
Provider Name (Legal Business Name): MARK A MAESTAS YOUTHCARE SPECIALIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2009
Last Update Date: 03/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 SUTTER PLACE
CLOVIS NM
88101
US

IV. Provider business mailing address

1100 W. 21ST STREET
CLOVIS NM
88101
US

V. Phone/Fax

Practice location:
  • Phone: 575-769-2345
  • Fax: 575-769-9013
Mailing address:
  • Phone: 575-769-2345
  • Fax: 575-769-9013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: