=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730131848
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIA CHRISTI MEDICAL CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2006
-----------------------------------------------------
Last Update Date | 11/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 E MANANA BLVD UNIT 1
-----------------------------------------------------
City | CLOVIS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88101-3503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-742-2500
-----------------------------------------------------
Fax | 575-742-9878
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 520
-----------------------------------------------------
City | CLOVIS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88102-0520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-742-2500
-----------------------------------------------------
Fax | 575-742-9878
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC ADMINISTRATOR
-----------------------------------------------------
Name | DR. HARRY KYLE SHEETS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 575-742-2500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 2001-306
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------