Provider Demographics
NPI:1831141258
Name:PECOS VALLEY OF NEW MEXICO, LLC
Entity Type:Organization
Organization Name:PECOS VALLEY OF NEW MEXICO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:V
Authorized Official - Middle Name:KAREN
Authorized Official - Last Name:FLINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-579-0315
Mailing Address - Street 1:2420 W PIERCE ST
Mailing Address - Street 2:STE 100
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-3543
Mailing Address - Country:US
Mailing Address - Phone:505-628-8837
Mailing Address - Fax:
Practice Address - Street 1:2420 W PIERCE ST
Practice Address - Street 2:STE 100
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3543
Practice Address - Country:US
Practice Address - Phone:505-628-8837
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB4739Medicaid