Healthcare Provider Details

I. General information

NPI: 1245295112
Provider Name (Legal Business Name): CLOVIS VA OUTPATIENT CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 E LLANO ESTACADO BLVD
CLOVIS NM
88101-3807
US

IV. Provider business mailing address

921 E LLANO ESTACADO BLVD
CLOVIS NM
88101-3807
US

V. Phone/Fax

Practice location:
  • Phone: 505-763-4335
  • Fax: 505-763-4296
Mailing address:
  • Phone: 505-763-4335
  • Fax: 505-763-4296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. STEVEN KOLB KINCAID
Title or Position: PHYSICIAN'S ASSISTANT
Credential: PA-C
Phone: 505-763-4335