Healthcare Provider Details

I. General information

NPI: 1609001684
Provider Name (Legal Business Name): MATT 25 INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2009
Last Update Date: 05/08/2021
Certification Date: 05/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 THORNTON ST STE A
CLOVIS NM
88101-5508
US

IV. Provider business mailing address

1200 THORNTON ST STE A
CLOVIS NM
88101-5508
US

V. Phone/Fax

Practice location:
  • Phone: 575-763-4400
  • Fax: 575-935-0400
Mailing address:
  • Phone: 575-763-4400
  • Fax: 575-935-0400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0153271
License Number StateNM

VIII. Authorized Official

Name: MR. STEVE RESHETAR
Title or Position: DIRECTOR
Credential:
Phone: 575-763-4400