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General NPI Number Information
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NPI Number | 1740688548
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Entity Type | Organization
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Legal Business Name | NORTHERN NEW MEXICO SURGICAL SERVICES PC
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Dates
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Enumeration Date | 12/09/2014
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Last Update Date | 01/22/2015
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Provider Practice Location Address
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Address Line | 300 WILSON ST
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City | CLAYTON
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State | NM
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Zip | 88415-3304
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Country | US
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Telephone | 575-374-0021
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 545
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City | CLAYTON
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State | NM
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Zip | 88415-0545
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Country | US
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Telephone | 575-374-0021
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING ASSISTANT
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Name | JACQUE CALLIS
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Credential |
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Telephone | 575-207-8890
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | MD2013-0738
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License Number State | NM
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