Healthcare Provider Details

I. General information

NPI: 1780683292
Provider Name (Legal Business Name): WOMEN'S MEDICAL CENTER LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 05/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W 21ST ST SUITE A-1
CLOVIS NM
88101-4087
US

IV. Provider business mailing address

2000 W 21ST ST SUITE A-1
CLOVIS NM
88101-4087
US

V. Phone/Fax

Practice location:
  • Phone: 505-762-8055
  • Fax: 505-763-3351
Mailing address:
  • Phone: 505-762-8055
  • Fax: 505-763-3351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number8738
License Number StateNM

VIII. Authorized Official

Name: LONNIE RAY
Title or Position: ADMINISTRATOR
Credential:
Phone: 575-762-8055