Healthcare Provider Details

I. General information

NPI: 1144956533
Provider Name (Legal Business Name): PRIORITY MEDICAL AND HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 W COUNTRY CLUB RD STE 6
ROSWELL NM
88201-5804
US

IV. Provider business mailing address

PO BOX 8244
ROSWELL NM
88202-8244
US

V. Phone/Fax

Practice location:
  • Phone: 575-291-1110
  • Fax: 575-205-4165
Mailing address:
  • Phone: 575-291-1110
  • Fax: 575-205-4165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RUBEN ALFARO SUPAN
Title or Position: OWNER
Credential: CNP
Phone: 505-409-0831