Provider Demographics
NPI:1003143660
Name:SOUTHWEST CENTER ON AGING
Entity Type:Organization
Organization Name:SOUTHWEST CENTER ON AGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:ROBERTO
Authorized Official - Last Name:DURAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-647-8366
Mailing Address - Street 1:PO BOX 14232
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88013-4232
Mailing Address - Country:US
Mailing Address - Phone:575-647-8366
Mailing Address - Fax:575-647-8381
Practice Address - Street 1:2467 S TELSHOR BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5049
Practice Address - Country:US
Practice Address - Phone:575-647-8366
Practice Address - Fax:575-647-8381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-03
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2008-0053207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty