Healthcare Provider Details

I. General information

NPI: 1336637727
Provider Name (Legal Business Name): DAVID ESTABILLO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W 21ST ST STE E3
CLOVIS NM
88101-4093
US

IV. Provider business mailing address

PO BOX 1161
CLOVIS NM
88102-1161
US

V. Phone/Fax

Practice location:
  • Phone: 954-655-3570
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID ESTABILLO
Title or Position: OWNER
Credential: CNP
Phone: 954-655-3570