Healthcare Provider Details

I. General information

NPI: 1609686013
Provider Name (Legal Business Name): TRACY LEE HARBUCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2025
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N CALIFORNIA ST
SOCORRO NM
87801-4254
US

IV. Provider business mailing address

62 E ST
ROSWELL NM
88203-8406
US

V. Phone/Fax

Practice location:
  • Phone: 575-622-6299
  • Fax:
Mailing address:
  • Phone: 575-291-5613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: