Healthcare Provider Details

I. General information

NPI: 1487290623
Provider Name (Legal Business Name): MICHAEL P. CLEMENTS MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2019
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1096 MECHEM DR STE G05
RUIDOSO NM
88345-7057
US

IV. Provider business mailing address

1096 MECHEM DR STE G05
RUIDOSO NM
88345-7057
US

V. Phone/Fax

Practice location:
  • Phone: 575-973-5864
  • Fax: 575-258-2648
Mailing address:
  • Phone: 575-973-5864
  • Fax: 575-258-2648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL P CLEMENTS
Title or Position: SOLE PROPRIETOR
Credential: MD
Phone: 575-973-5864