Healthcare Provider Details

I. General information

NPI: 1649251679
Provider Name (Legal Business Name): CLOVIS SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 W 21ST ST
CLOVIS NM
88101-4024
US

IV. Provider business mailing address

1820 W 21ST ST
CLOVIS NM
88101-4024
US

V. Phone/Fax

Practice location:
  • Phone: 575-762-2207
  • Fax: 575-762-7108
Mailing address:
  • Phone: 575-762-2207
  • Fax: 575-762-7108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number3042
License Number StateNM

VIII. Authorized Official

Name: ALBERT M KWAN
Title or Position: OWNER
Credential: MD
Phone: 575-762-2207