Full Name | |
---|---|
Speciality | Clinic/center - Federally Qualified Health Center (fqhc) |
Location | 375 East 6th Street, Roy, New Mexico |
Authorized Official Name and Position | Lore Pease (CEO) |
Authorized Official Contact | 5057537218 |
Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
Mailing Address | Practice Location Address |
---|---|
538 N Paseo De Onate P.o. Box 158 Espanola NM 87532-2618 Ph: (505) 753-7218 | 375 East 6th Street Roy NM 87743 Ph: (575) 485-0019 |
NPI Number | 1225306525 |
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Provider Enumeration Date | 12/01/2011 |
Last Update Date | 03/22/2016 |
Identifier | Type | State | Issuer |
---|---|---|---|
1225306525 | NPI | - | NPPES |
1780689034 | Other | NM | NPPES |
58957553 | Medicaid | NM |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | 2015/16-19 (New Mexico) | Primary |