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General NPI Number Information
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NPI Number | 1245295112
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Entity Type | Organization
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Legal Business Name | CLOVIS VA OUTPATIENT CARE CLINIC
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Dates
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Enumeration Date | 04/20/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 921 E LLANO ESTACADO BLVD
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City | CLOVIS
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State | NM
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Zip | 88101-3807
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Country | US
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Telephone | 505-763-4335
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Fax | 505-763-4296
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Provider Business Mailing Address
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Address Line | 921 E LLANO ESTACADO BLVD
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City | CLOVIS
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State | NM
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Zip | 88101-3807
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Country | US
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Telephone | 505-763-4335
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Fax | 505-763-4296
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Authorized Official
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Title or Position | PHYSICIAN'S ASSISTANT
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Name | MR. STEVEN KOLB KINCAID
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Credential | PA-C
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Telephone | 505-763-4335
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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 |
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License Number State |
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