Provider Demographics
NPI:1003186248
Name:WEST VALLEY CLINIC, LLC
Entity Type:Organization
Organization Name:WEST VALLEY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:TYSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-877-3151
Mailing Address - Street 1:6898 DONIPHAN DRIVE
Mailing Address - Street 2:P.O BOX 2076
Mailing Address - City:CANUTILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79835-2076
Mailing Address - Country:US
Mailing Address - Phone:915-877-3151
Mailing Address - Fax:915-877-5346
Practice Address - Street 1:6898 DONIPHAN DRIVE
Practice Address - Street 2:
Practice Address - City:CANUTILLO
Practice Address - State:TX
Practice Address - Zip Code:79835-2076
Practice Address - Country:US
Practice Address - Phone:915-877-3151
Practice Address - Fax:915-877-5346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-05
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2185261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138392907Medicaid
TX138392907Medicaid