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General NPI Number Information
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NPI Number | 1407382567
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Entity Type | Organization
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Legal Business Name | PECOS VALLEY WELLNESS LLC
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Dates
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Enumeration Date | 05/11/2017
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Last Update Date | 05/11/2017
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Provider Practice Location Address
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Address Line | 401 N UNION AVE
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City | ROSWELL
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State | NM
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Zip | 88201-3948
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Country | US
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Telephone | 575-291-9814
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Fax | 575-587-3987
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Provider Business Mailing Address
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Address Line | 401 N UNION AVE
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City | ROSWELL
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State | NM
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Zip | 88201-3948
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Country | US
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Telephone | 575-291-9814
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Fax | 575-587-3987
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | MR. STEPHEN WAYNE MUHR
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Credential | PA
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Telephone | 575-291-9814
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | PA2009-0030
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License Number State | NM
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