Healthcare Provider Details

I. General information

NPI: 1669697264
Provider Name (Legal Business Name): PECOS COUNTY MEMORIAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 11/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

387 W IH 10
FORT STOCKTON TX
79735-2700
US

IV. Provider business mailing address

387 W IH 10
FORT STOCKTON TX
79735-2700
US

V. Phone/Fax

Practice location:
  • Phone: 432-336-2291
  • Fax: 844-824-3604
Mailing address:
  • Phone: 432-336-4880
  • Fax: 844-824-3604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MELISSA PENA
Title or Position: DIRECTOR
Credential:
Phone: 432-336-4880