Healthcare Provider Details

I. General information

NPI: 1760123475
Provider Name (Legal Business Name): CLOVIS FAMILY HEALTH CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 06/26/2022
Certification Date: 06/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 N DR MARTIN LUTHER KING JR BLVD
CLOVIS NM
88101-9401
US

IV. Provider business mailing address

PO BOX 1087
CLOVIS NM
88102-1087
US

V. Phone/Fax

Practice location:
  • Phone: 575-762-4455
  • Fax:
Mailing address:
  • Phone: 575-760-1365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BLAKE O'HARE
Title or Position: OWNER
Credential:
Phone: 575-760-1365