Healthcare Provider Details

I. General information

NPI: 1003464652
Provider Name (Legal Business Name): PINON HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 E 20TH ST STE B
FARMINGTON NM
87401-4281
US

IV. Provider business mailing address

PO BOX 166
FARMINGTON NM
87499-0166
US

V. Phone/Fax

Practice location:
  • Phone: 505-787-2680
  • Fax: 505-787-2668
Mailing address:
  • Phone: 505-787-2680
  • Fax: 505-787-2668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DIKILYN TYSON
Title or Position: OWNER
Credential:
Phone: 505-860-5180