Healthcare Provider Details

I. General information

NPI: 1912512542
Provider Name (Legal Business Name): CLOVIS SURGERY CENTER NM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2020
Last Update Date: 09/10/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 W 21ST ST
CLOVIS NM
88101-4024
US

IV. Provider business mailing address

921 E 21ST ST STE C
CLOVIS NM
88101-4443
US

V. Phone/Fax

Practice location:
  • Phone: 575-935-3668
  • Fax: 575-935-3669
Mailing address:
  • Phone: 575-935-3668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DEVIN WAHLEN
Title or Position: OWNER
Credential: DPM
Phone: 575-935-3668