Healthcare Provider Details

I. General information

NPI: 1790370823
Provider Name (Legal Business Name): JESUS VALENTIN FLORES VILLANUEVA SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

3500 FOOTHILLS RD APT H1
LAS CRUCES NM
88011-3618
US

IV. Provider business mailing address

3500 FOOTHILLS RD APT H1
LAS CRUCES NM
88011-3618
US

V. Phone/Fax

Practice location:
  • Phone: 915-207-4570
  • Fax:
Mailing address:
  • Phone: 915-207-4570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number21-154
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: