Healthcare Provider Details

I. General information

NPI: 1972758688
Provider Name (Legal Business Name): COUNTRY MEDICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2008
Last Update Date: 10/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NM STATE HIGHWAY 120, #1252 (FYI RURAL ADDRESS) POB 203
OCATE NM
87734-0203
US

IV. Provider business mailing address

# 1252, NM STATE HIGHWAY 120 (FYI RURAL ADDRESS) POB 203
OCATE NM
87734-0203
US

V. Phone/Fax

Practice location:
  • Phone: 575-666-2475
  • Fax:
Mailing address:
  • Phone: 575-666-2475
  • Fax: 800-560-1129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberR24775
License Number StateNM

VIII. Authorized Official

Name: MS. DIANA LOUISE LEWIS
Title or Position: OWNER OF BUSINESS/ NP-C PROVIDER
Credential: NP-C
Phone: 575-666-2475