=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881089886
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHWEST PEDIATRIC AND FAMILY CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2015
-----------------------------------------------------
Last Update Date | 05/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1020 S 8TH ST SUITE A
-----------------------------------------------------
City | DEMING
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88030-4007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-936-4350
-----------------------------------------------------
Fax | 575-936-4351
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1020 S 8TH ST A
-----------------------------------------------------
City | DEMING
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88030-4007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-936-4350
-----------------------------------------------------
Fax | 575-936-4351
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO / CO-OWNER
-----------------------------------------------------
Name | MR. JOEL RENE ROQUE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 575-936-4350
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------