Healthcare Provider Details

I. General information

NPI: 1366631616
Provider Name (Legal Business Name): SIEVERS SPORTS MEDICINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 03/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 S MAIN AVE
PORTALES NM
88130-6218
US

IV. Provider business mailing address

PO BOX 55
PORTALES NM
88130-0055
US

V. Phone/Fax

Practice location:
  • Phone: 575-226-3023
  • Fax: 575-226-3024
Mailing address:
  • Phone: 575-226-3023
  • Fax: 575-226-3024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2002-0109
License Number StateNM

VIII. Authorized Official

Name: DR. JOEL WILLIAM SIEVERS
Title or Position: PRESIDENT/DIRECTOR
Credential: M.D.
Phone: 575-226-3023