Healthcare Provider Details

I. General information

NPI: 1962499509
Provider Name (Legal Business Name): DUDE SLATE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E BENDER BLVD SUITE 120
HOBBS NM
88240-2331
US

IV. Provider business mailing address

1839 N BRAZOS AVE
HOBBS NM
88240-3225
US

V. Phone/Fax

Practice location:
  • Phone: 505-393-8470
  • Fax: 505-393-8476
Mailing address:
  • Phone: 505-318-1046
  • Fax: 505-393-8476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number232
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: