Provider Demographics
NPI:1497801047
Name:PECOS VALLEY MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:PECOS VALLEY MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:NORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-757-6482
Mailing Address - Street 1:PO BOX 710
Mailing Address - Street 2:
Mailing Address - City:PECOS
Mailing Address - State:NM
Mailing Address - Zip Code:87552-0710
Mailing Address - Country:US
Mailing Address - Phone:505-757-6482
Mailing Address - Fax:505-757-2700
Practice Address - Street 1:199 HWY 50
Practice Address - Street 2:
Practice Address - City:PECOS
Practice Address - State:NM
Practice Address - Zip Code:87552-0710
Practice Address - Country:US
Practice Address - Phone:505-757-6482
Practice Address - Fax:505-757-2700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6263261QC1500X
NMCL000071203336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM046623Medicaid
NM046623Medicaid