Provider Demographics
NPI:1508840117
Name:MORA VALLEY COMMUNITY HEALTH SERVICES INC
Entity Type:Organization
Organization Name:MORA VALLEY COMMUNITY HEALTH SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:RENAY
Authorized Official - Last Name:SALAZAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-387-5069
Mailing Address - Street 1:PO BOX 209
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:NM
Mailing Address - Zip Code:87732
Mailing Address - Country:US
Mailing Address - Phone:575-387-5069
Mailing Address - Fax:575-387-9011
Practice Address - Street 1:13 MORA VALLEY CLINIC ROAD
Practice Address - Street 2:STATE HWY 518 MILE MARKER 26
Practice Address - City:MORA
Practice Address - State:NM
Practice Address - Zip Code:87732-0209
Practice Address - Country:US
Practice Address - Phone:575-387-5069
Practice Address - Fax:575-387-9011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6333261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM48504Medicaid
NM321803Medicare ID - Type UnspecifiedMEDICARE
NM48504Medicaid
NM321803Medicare Oscar/Certification