Healthcare Provider Details

I. General information

NPI: 1114096138
Provider Name (Legal Business Name): CAROL E. EDWARDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 10/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 N MAIN ST
CLOVIS NM
88101-4747
US

IV. Provider business mailing address

1423 N MAIN ST
CLOVIS NM
88101-4747
US

V. Phone/Fax

Practice location:
  • Phone: 575-935-4357
  • Fax: 575-935-4358
Mailing address:
  • Phone: 575-935-4357
  • Fax: 575-935-4358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNM

VIII. Authorized Official

Name: MS. CAROL ELIZABETH EDWARDS
Title or Position: OWNER
Credential:
Phone: 505-935-4357