Healthcare Provider Details

I. General information

NPI: 1003444647
Provider Name (Legal Business Name): CIBOLA SPECIALTY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 BONITA ST
GRANTS NM
87020-2234
US

IV. Provider business mailing address

1016 E ROOSEVELT AVE
GRANTS NM
87020-2118
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-4446
  • Fax:
Mailing address:
  • Phone: 505-287-4446
  • Fax: 505-287-5213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: THOMAS WHELAN
Title or Position: CEO
Credential:
Phone: 505-287-5300