Healthcare Provider Details

I. General information

NPI: 1073594446
Provider Name (Legal Business Name): SOUTHEASTERN NEW MEXICO SURGICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 E 19TH ST
ROSWELL NM
88201-5151
US

IV. Provider business mailing address

113 E 19TH ST
ROSWELL NM
88201-5151
US

V. Phone/Fax

Practice location:
  • Phone: 505-627-7000
  • Fax: 505-627-7007
Mailing address:
  • Phone: 505-627-7000
  • Fax: 505-627-7007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number6786
License Number StateNM

VIII. Authorized Official

Name: MRS. LAURI J ROSE
Title or Position: ADMINISTRATOR
Credential: MBA, CASC
Phone: 505-627-7000