Provider Demographics
NPI:1245295112
Name:CLOVIS VA OUTPATIENT CARE CLINIC
Entity type:Organization
Organization Name:CLOVIS VA OUTPATIENT CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN'S ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:KOLB
Authorized Official - Last Name:KINCAID
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:505-763-4335
Mailing Address - Street 1:921 E LLANO ESTACADO BLVD
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-3807
Mailing Address - Country:US
Mailing Address - Phone:505-763-4335
Mailing Address - Fax:505-763-4296
Practice Address - Street 1:921 E LLANO ESTACADO BLVD
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-3807
Practice Address - Country:US
Practice Address - Phone:505-763-4335
Practice Address - Fax:505-763-4296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center