| West Valley Clinic, Llc | |
|
6898 Doniphan Drive Canutillo TX 79835-2076 | |
| (915) 877-3151 | |
| (915) 877-5346 |
| Full Name | West Valley Clinic, Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 6898 Doniphan Drive, Canutillo, Texas |
| Authorized Official Name and Position | Sam T Tyson (COO/MANAGER) |
| Authorized Official Contact | 9158773151 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| West Valley Clinic, Llc 6898 Doniphan Drive P.o Box 2076 Canutillo TX 79835-2076 Ph: (915) 877-3151 | West Valley Clinic, Llc 6898 Doniphan Drive Canutillo TX 79835-2076 Ph: (915) 877-3151 |
| NPI Number | 1003186248 |
|---|---|
| Provider Enumeration Date | 01/05/2012 |
| Last Update Date | 09/10/2020 |
| Medicare PECOS PAC ID | 0840610143 |
|---|---|
| Medicare Enrollment ID | O20201026000352 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1003186248 | NPI | - | NPPES |
| 138392907 | Medicaid | TX |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | H2185 (Texas) | Primary |
| Provider Name | Samuel T Tyson |
|---|---|
| Provider Type | Practitioner - General Practice |
| Provider Identifiers | NPI Number: 1659323848 PECOS PAC ID: 8426351461 Enrollment ID: I20201026000462 |
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