Provider Demographics
NPI:1023151966
Name:RIO PECOS MEDICAL ASSOCIATES LTD
Entity type:Organization
Organization Name:RIO PECOS MEDICAL ASSOCIATES LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CODY
Authorized Official - Middle Name:
Authorized Official - Last Name:DODSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-622-6322
Mailing Address - Street 1:PO BOX 2608
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-2608
Mailing Address - Country:US
Mailing Address - Phone:575-622-6322
Mailing Address - Fax:575-622-6888
Practice Address - Street 1:305 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5892
Practice Address - Country:US
Practice Address - Phone:575-622-6322
Practice Address - Fax:575-622-6888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM55526721Medicaid