Healthcare Provider Details

I. General information

NPI: 1366773947
Provider Name (Legal Business Name): UPPER VALLEY MEDICAL CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2010
Last Update Date: 01/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 ANTHONY ST
CANUTILLO TX
79835-6052
US

IV. Provider business mailing address

7250 NINTH ST
CANUTILLO TX
79835-6011
US

V. Phone/Fax

Practice location:
  • Phone: 915-877-4217
  • Fax: 915-877-4231
Mailing address:
  • Phone: 915-877-4217
  • Fax: 915-877-4231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number537539
License Number StateTX

VIII. Authorized Official

Name: MS. ANNA M LUCERO
Title or Position: OWNER/PRESIDENT
Credential: FNP-C
Phone: 915-877-4217