=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972528891
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHITE SANDS FAMILY PRACTICE CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2006
-----------------------------------------------------
Last Update Date | 11/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 916 N WHITE SANDS BLVD
-----------------------------------------------------
City | ALAMOGORDO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88310-6926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-488-2720
-----------------------------------------------------
Fax | 575-936-4077
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 836
-----------------------------------------------------
City | ALAMOGORDO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88311-0836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-488-2720
-----------------------------------------------------
Fax | 575-488-2721
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE ADMINISTRATOR
-----------------------------------------------------
Name | MRS. AMBER BRYANT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 575-488-2720
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 98-288
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------