Healthcare Provider Details

I. General information

NPI: 1326025115
Provider Name (Legal Business Name): VILLAGE OF DORA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 04/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 AVE A
DORA NM
88115-0308
US

IV. Provider business mailing address

PO BOX 308 220 AVE A
DORA NM
88115-0308
US

V. Phone/Fax

Practice location:
  • Phone: 575-477-2411
  • Fax: 575-477-2418
Mailing address:
  • Phone: 575-477-2411
  • Fax: 575-477-2418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number38200
License Number StateNM

VIII. Authorized Official

Name: MRS. BECKY FRAZE
Title or Position: CLERK
Credential:
Phone: 575-477-2411