Healthcare Provider Details

I. General information

NPI: 1730101676
Provider Name (Legal Business Name): PORTALES MEDICAL CLINIC LIMITED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 S AVENUE A
PORTALES NM
88130-6278
US

IV. Provider business mailing address

320 S AVENUE A
PORTALES NM
88130-6278
US

V. Phone/Fax

Practice location:
  • Phone: 505-356-4643
  • Fax: 505-359-6856
Mailing address:
  • Phone: 505-356-4643
  • Fax: 505-359-6856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID L JONES
Title or Position: PRACTITIONER/OWNER
Credential: NP-C
Phone: 505-356-4643