Healthcare Provider Details

I. General information

NPI: 1235597964
Provider Name (Legal Business Name): TAOS PROFESSIONAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1329 GUSDORF RD
TAOS NM
87571-6282
US

IV. Provider business mailing address

1397 WEIMER RD
TAOS NM
87571-6253
US

V. Phone/Fax

Practice location:
  • Phone: 575-737-3415
  • Fax: 575-737-3416
Mailing address:
  • Phone: 575-751-8900
  • Fax: 575-751-3723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4075
License Number StateNM

VIII. Authorized Official

Name: MR. BILL PATTEN
Title or Position: CEO
Credential:
Phone: 575-751-5714