Healthcare Provider Details

I. General information

NPI: 1750143616
Provider Name (Legal Business Name): HERMAN EUGENE CHAVEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2024
Last Update Date: 01/26/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7450 SKYHAWK LP
NEWCOMB NM
87455
US

IV. Provider business mailing address

2495 PARKLANE DR
BOSQUE FARMS NM
87068-9397
US

V. Phone/Fax

Practice location:
  • Phone: 505-463-8207
  • Fax:
Mailing address:
  • Phone: 505-463-8207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number506289451
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: