Healthcare Provider Details

I. General information

NPI: 1346272499
Provider Name (Legal Business Name): EASTERN MEDICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42121 US HWY 70
PORTALES NM
88130-9357
US

IV. Provider business mailing address

PO BOX 510 42121 US HWY 70
PORTALES NM
88130-0510
US

V. Phone/Fax

Practice location:
  • Phone: 575-356-6652
  • Fax: 575-359-6827
Mailing address:
  • Phone: 575-356-6652
  • Fax: 575-359-6827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGIE PARKS
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 575-356-6653