Healthcare Provider Details

I. General information

NPI: 1437570728
Provider Name (Legal Business Name): ROOSEVELT COUNTY SPECIAL HOSPITAL DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2014
Last Update Date: 03/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42121 U.S. 70
PORTALES NM
88130-9054
US

IV. Provider business mailing address

PO BOX 568
MUNCIE IN
47308-0568
US

V. Phone/Fax

Practice location:
  • Phone: 575-359-1800
  • Fax:
Mailing address:
  • Phone: 765-284-0493
  • Fax: 765-284-2434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: LARRY LEAMING
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 575-356-3412