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General NPI Number Information
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NPI Number | 1679516702
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Entity Type | Organization
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Legal Business Name | THOREAU CLINIC
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Dates
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Enumeration Date | 06/14/2006
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Last Update Date | 10/18/2012
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Provider Practice Location Address
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Address Line | 3 NAVARRE STREET
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City | THOREAU
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State | NM
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Zip | 87323
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Country | US
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Telephone | 505-862-8250
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Fax | 505-862-8909
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Provider Business Mailing Address
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Address Line | PO BOX 358
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City | CROWNPOINT
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State | NM
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Zip | 87313-0358
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Country | US
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Telephone | 505-786-5291
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Fax | 505-786-6440
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Authorized Official
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Title or Position | CEO
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Name | MR. ANSLEM ROANHORSE
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Credential |
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Telephone | 505-786-5291
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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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