Healthcare Provider Details

I. General information

NPI: 1699224758
Provider Name (Legal Business Name): KWD SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2016
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S 15TH ST
WORLAND WY
82401-3531
US

IV. Provider business mailing address

7320 AVENIDA LA COSTA NE
ALBUQUERQUE NM
87109-3955
US

V. Phone/Fax

Practice location:
  • Phone: 702-453-3799
  • Fax: 702-453-5741
Mailing address:
  • Phone: 702-453-3799
  • Fax: 702-453-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KEITH DAVIS
Title or Position: SOLE OWNER
Credential: M.D.
Phone: 505-203-4786