Provider Demographics
NPI:1730131848
Name:VIA CHRISTI MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:VIA CHRISTI MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:SHEETS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-742-2500
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88102-0520
Mailing Address - Country:US
Mailing Address - Phone:575-742-2500
Mailing Address - Fax:575-742-9878
Practice Address - Street 1:100 E MANANA BLVD
Practice Address - Street 2:UNIT 1
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-3503
Practice Address - Country:US
Practice Address - Phone:575-742-2500
Practice Address - Fax:575-742-9878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2001-306207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM80739237Medicaid
NMP00119862OtherRAILROAD MEDICARE PIN
NM80739237Medicaid