Healthcare Provider Details

I. General information

NPI: 1619200656
Provider Name (Legal Business Name): JOHNNY RAY FLORES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 DEMOSS STREET
LORDSBURG NM
88045-2618
US

IV. Provider business mailing address

530 DEMOSS STREET
LORDSBURG NM
88045-2618
US

V. Phone/Fax

Practice location:
  • Phone: 575-542-8384
  • Fax: 575-542-8367
Mailing address:
  • Phone: 575-542-2370
  • Fax: 575-542-8367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: