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General NPI Number Information
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NPI Number | 1912512542
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Entity Type | Organization
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Legal Business Name | CLOVIS SURGERY CENTER NM LLC
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Dates
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Enumeration Date | 09/10/2020
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Last Update Date | 09/10/2020
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Provider Practice Location Address
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Address Line | 1820 W 21ST ST
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City | CLOVIS
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State | NM
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Zip | 88101-4024
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Country | US
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Telephone | 575-935-3668
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Fax | 575-935-3669
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Provider Business Mailing Address
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Address Line | 921 E 21ST ST STE C
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City | CLOVIS
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State | NM
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Zip | 88101-4443
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Country | US
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Telephone | 575-935-3668
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DEVIN WAHLEN
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Credential | DPM
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Telephone | 575-935-3668
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XX0004X
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Taxonomy Name | Orthopaedic Foot and Ankle Surgery Physician
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License Number |
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License Number State |
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