=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225737539
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONCHO VALLEY MEDICINE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2023
-----------------------------------------------------
Last Update Date | 02/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 S ABE ST
-----------------------------------------------------
City | SAN ANGELO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76903-6305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-414-6102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 223 S ABE ST
-----------------------------------------------------
City | SAN ANGELO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76903-6305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-374-0821
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER
-----------------------------------------------------
Name | DR. BRYAN A MEJIA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 407-414-6102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------