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General NPI Number Information
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NPI Number | 1003186248
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Entity Type | Organization
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Legal Business Name | WEST VALLEY CLINIC, LLC
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Dates
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Enumeration Date | 01/05/2012
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Last Update Date | 09/10/2020
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Provider Practice Location Address
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Address Line | 6898 DONIPHAN DRIVE
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City | CANUTILLO
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State | TX
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Zip | 79835-2076
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Country | US
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Telephone | 915-877-3151
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Fax | 915-877-5346
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Provider Business Mailing Address
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Address Line | 6898 DONIPHAN DRIVE P.O BOX 2076
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City | CANUTILLO
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State | TX
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Zip | 79835-2076
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Country | US
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Telephone | 915-877-3151
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Fax | 915-877-5346
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Authorized Official
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Title or Position | COO/MANAGER
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Name | SAM T TYSON
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Credential | M.D.
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Telephone | 915-877-3151
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | H2185
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License Number State | TX
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