Healthcare Provider Details

I. General information

NPI: 1881089886
Provider Name (Legal Business Name): SOUTHWEST PEDIATRIC AND FAMILY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 S 8TH ST SUITE A
DEMING NM
88030-4007
US

IV. Provider business mailing address

1020 S 8TH ST A
DEMING NM
88030-4007
US

V. Phone/Fax

Practice location:
  • Phone: 575-936-4350
  • Fax: 575-936-4351
Mailing address:
  • Phone: 575-936-4350
  • Fax: 575-936-4351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JOEL RENE ROQUE
Title or Position: COO / CO-OWNER
Credential:
Phone: 575-936-4350