Healthcare Provider Details

I. General information

NPI: 1396104964
Provider Name (Legal Business Name): MORA VALLEY COMMUNITY HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2016
Last Update Date: 02/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 RANGER DR
MORA NM
87732
US

IV. Provider business mailing address

PO BOX 209
MORA NM
87732-0209
US

V. Phone/Fax

Practice location:
  • Phone: 575-387-3117
  • Fax:
Mailing address:
  • Phone: 575-387-5069
  • Fax: 575-387-9011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number6333
License Number StateNM

VIII. Authorized Official

Name: JULIAN F BARELA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 575-387-5069