Healthcare Provider Details

I. General information

NPI: 1952585184
Provider Name (Legal Business Name): BRAZOS VALLEY CARDIO RESPIRATORY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 04/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141-A MESCALERO TR.
RUIDOSO NM
88345
US

IV. Provider business mailing address

141-A MESCALERO TR.
RUIDOSO NM
88345
US

V. Phone/Fax

Practice location:
  • Phone: 575-257-5083
  • Fax: 575-257-5083
Mailing address:
  • Phone: 575-257-5083
  • Fax: 575-257-5083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number56124
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number0059159
License Number StateTX

VIII. Authorized Official

Name: MR. KEVIN E MILLER
Title or Position: OWNER
Credential: RRT/RCP
Phone: 575-257-5083