Healthcare Provider Details

I. General information

NPI: 1265226823
Provider Name (Legal Business Name): TIFFANY LOPEZ CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2025
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S DIAMOND AVE
DEMING NM
88030-3752
US

IV. Provider business mailing address

300 S DIAMOND AVE
DEMING NM
88030-3752
US

V. Phone/Fax

Practice location:
  • Phone: 575-546-4663
  • Fax: 505-443-8331
Mailing address:
  • Phone: 575-546-4663
  • Fax: 505-443-8331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: