Healthcare Provider Details

I. General information

NPI: 1497801047
Provider Name (Legal Business Name): PECOS VALLEY MEDICAL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 09/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 HWY 50
PECOS NM
87552-0710
US

IV. Provider business mailing address

PO BOX 710
PECOS NM
87552-0710
US

V. Phone/Fax

Practice location:
  • Phone: 505-757-6482
  • Fax: 505-757-2700
Mailing address:
  • Phone: 505-757-6482
  • Fax: 505-757-2700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberCL00007120
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number6263
License Number StateNM

VIII. Authorized Official

Name: MR. KEVIN NORRIS
Title or Position: CFO
Credential:
Phone: 505-757-6482