Provider Demographics
NPI:1710127220
Name:ROSWELL MEDICAL CARE
Entity Type:Organization
Organization Name:ROSWELL MEDICAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-623-3311
Mailing Address - Street 1:111 W HOBBS
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203
Mailing Address - Country:US
Mailing Address - Phone:575-623-3311
Mailing Address - Fax:575-622-1273
Practice Address - Street 1:111 W HOBBS
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203
Practice Address - Country:US
Practice Address - Phone:575-623-3311
Practice Address - Fax:575-622-1273
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROSWELL OSTEOPATHIC MEDICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization