Provider Demographics
NPI:1407382567
Name:PECOS VALLEY WELLNESS LLC
Entity Type:Organization
Organization Name:PECOS VALLEY WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:MUHR
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:575-291-9814
Mailing Address - Street 1:401 N UNION AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-3948
Mailing Address - Country:US
Mailing Address - Phone:575-291-9814
Mailing Address - Fax:575-587-3987
Practice Address - Street 1:401 N UNION AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-3948
Practice Address - Country:US
Practice Address - Phone:575-291-9814
Practice Address - Fax:575-587-3987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2009-0030261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care