Healthcare Provider Details

I. General information

NPI: 1053458240
Provider Name (Legal Business Name): MOMS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 03/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1329 GUSDORF RD
TAOS NM
87571-6282
US

IV. Provider business mailing address

1329 GUSDORF RD
TAOS NM
87571-6282
US

V. Phone/Fax

Practice location:
  • Phone: 575-737-6504
  • Fax: 575-737-6504
Mailing address:
  • Phone: 575-737-6504
  • Fax: 575-737-6504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number6432
License Number StateNM

VIII. Authorized Official

Name: MR. WARREN K SPELLMAN
Title or Position: CEO
Credential:
Phone: 575-751-5714