Full Name | |
---|---|
Speciality | Clinic/Center |
Location | 415 Hwy 211, Gila, New Mexico |
Authorized Official Name and Position | Daniel Otero (CEO) |
Authorized Official Contact | 5755422322 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
---|---|
530 De Moss St Lordsburg NM 88045-2618 Ph: (575) 542-2368 | 415 Hwy 211 Gila NM 88038-9800 Ph: (575) 535-4384 |
NPI Number | 1427041490 |
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Provider Enumeration Date | 08/25/2005 |
Last Update Date | 03/04/2016 |
Medicare PECOS PAC ID | 4587572250 |
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Medicare Enrollment ID | O20040316000579 |
Identifier | Type | State | Issuer |
---|---|---|---|
1427041490 | NPI | - | NPPES |
12007269 | Medicaid | NM |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | 3184 (New Mexico) | Primary |