Healthcare Provider Details

I. General information

NPI: 1114977675
Provider Name (Legal Business Name): EASTERN NEW MEXICO PHYSICIANS AND SURGEONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 05/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 W 21ST STREET
CLOVIS NM
88101
US

IV. Provider business mailing address

2425 W 21ST STREET
CLOVIS NM
88101
US

V. Phone/Fax

Practice location:
  • Phone: 505-763-9800
  • Fax: 505-769-1998
Mailing address:
  • Phone: 505-763-9800
  • Fax: 505-769-1998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LONNIE J RAY
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 505-763-9800