Healthcare Provider Details

I. General information

NPI: 1356401830
Provider Name (Legal Business Name): CLOVIS FAMILY HEALTHCARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 N MLK BLVD
CLOVIS NM
88101-9401
US

IV. Provider business mailing address

2301 N MLK BLVD
CLOVIS NM
88101-9401
US

V. Phone/Fax

Practice location:
  • Phone: 505-762-4455
  • Fax: 505-763-4029
Mailing address:
  • Phone: 505-762-4455
  • Fax: 505-763-4029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA112299
License Number StateNM

VIII. Authorized Official

Name: AMANDA SHRADER
Title or Position: OWNER
Credential:
Phone: 575-762-4455