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General NPI Number Information
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NPI Number | 1144327172
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Entity Type | Organization
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Legal Business Name | FOUR CORNERS NEPHROLOGY ASSOCIATES PC
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 04/01/2011
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Provider Practice Location Address
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Address Line | 622 W MAPLE ST STE H
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City | FARMINGTON
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State | NM
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Zip | 87401-6589
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Country | US
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Telephone | 505-326-6521
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Fax | 505-325-6699
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Provider Business Mailing Address
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Address Line | 622 W MAPLE ST STE H
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City | FARMINGTON
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State | NM
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Zip | 87401-6589
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Country | US
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Telephone | 505-326-6521
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Fax | 505-325-6699
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. BILLIE STOLWORTHY
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Credential |
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Telephone | 505-326-6521
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number |
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License Number State |
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