Provider Demographics
NPI:1760123475
Name:CLOVIS FAMILY HEALTH CARE CENTER LLC
Entity Type:Organization
Organization Name:CLOVIS FAMILY HEALTH CARE CENTER LLC
Other - Org Name:O'HARE WELLNESS LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:O'HARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-760-1365
Mailing Address - Street 1:PO BOX 1087
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88102-1087
Mailing Address - Country:US
Mailing Address - Phone:575-760-1365
Mailing Address - Fax:
Practice Address - Street 1:2301 N DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-9401
Practice Address - Country:US
Practice Address - Phone:575-762-4455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-05
Last Update Date:2022-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty