Healthcare Provider Details

I. General information

NPI: 1477627560
Provider Name (Legal Business Name): KELLY MICHAEL HARTZ MED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W 21ST MENTAL HEALTH RESOURCES
CLOVIS NM
88101
US

IV. Provider business mailing address

404 MAPLE
CLOVIS NM
88101
US

V. Phone/Fax

Practice location:
  • Phone: 505-769-2345
  • Fax: 505-769-8974
Mailing address:
  • Phone: 505-769-9128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: