Healthcare Provider Details

I. General information

NPI: 1003186248
Provider Name (Legal Business Name): WEST VALLEY CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2012
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6898 DONIPHAN DRIVE
CANUTILLO TX
79835-2076
US

IV. Provider business mailing address

6898 DONIPHAN DRIVE P.O BOX 2076
CANUTILLO TX
79835-2076
US

V. Phone/Fax

Practice location:
  • Phone: 915-877-3151
  • Fax: 915-877-5346
Mailing address:
  • Phone: 915-877-3151
  • Fax: 915-877-5346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberH2185
License Number StateTX

VIII. Authorized Official

Name: SAM T TYSON
Title or Position: COO/MANAGER
Credential: M.D.
Phone: 915-877-3151