Healthcare Provider Details

I. General information

NPI: 1184258444
Provider Name (Legal Business Name): JAMES DAILY CPSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JESSE JAMES DAILY

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 MCADOO ST STE B
T OR C NM
87901-2706
US

IV. Provider business mailing address

614 MCADOO ST STE B
T OR C NM
87901-2706
US

V. Phone/Fax

Practice location:
  • Phone: 575-297-0171
  • Fax: 575-894-7383
Mailing address:
  • Phone: 575-297-0171
  • Fax: 575-894-7383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1018
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: