Provider Demographics
NPI:1225737539
Name:CONCHO VALLEY MEDICINE, LLC
Entity Type:Organization
Organization Name:CONCHO VALLEY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MEJIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-414-6102
Mailing Address - Street 1:223 S ABE ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-6305
Mailing Address - Country:US
Mailing Address - Phone:325-374-0821
Mailing Address - Fax:
Practice Address - Street 1:225 S ABE ST
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-6305
Practice Address - Country:US
Practice Address - Phone:407-414-6102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP9224OtherTEXAS MEDICAL BOARD