Healthcare Provider Details

I. General information

NPI: 1689966442
Provider Name (Legal Business Name): CECIL LEWIS JR. PASTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2011
Last Update Date: 05/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

.5 MILES EAST OF HWY 371 .5 MILES EAST OF HWY 371
THOREAU NM
87323-1289
US

IV. Provider business mailing address

PO BOX 1289
THOREAU NM
87323-1289
US

V. Phone/Fax

Practice location:
  • Phone: 505-905-0061
  • Fax: 505-905-0064
Mailing address:
  • Phone: 505-905-0061
  • Fax: 505-905-0064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: