Healthcare Provider Details

I. General information

NPI: 1689833170
Provider Name (Legal Business Name): CROWNPOINT MOBILE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 371 NAVAJO JUNCTION ROUTE 9
CROWNPOINT NM
87313-0358
US

IV. Provider business mailing address

PO BOX 358
CROWNPOINT NM
87313-0358
US

V. Phone/Fax

Practice location:
  • Phone: 505-786-5291
  • Fax:
Mailing address:
  • Phone: 505-786-5291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARY ANN ONEAL
Title or Position: ADMINTRATIVE OFFICER
Credential:
Phone: 505-786-5291