Provider Demographics
NPI:1649251679
Name:CLOVIS SURGERY CENTER LLC
Entity type:Organization
Organization Name:CLOVIS SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:KWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-762-2207
Mailing Address - Street 1:1820 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4024
Mailing Address - Country:US
Mailing Address - Phone:575-762-2207
Mailing Address - Fax:575-762-7108
Practice Address - Street 1:1820 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4024
Practice Address - Country:US
Practice Address - Phone:575-762-2207
Practice Address - Fax:575-762-7108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3042261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0000F8949Medicaid
NM490005150OtherRAILROAD MEDICARE
NM0000F8949Medicaid
NM400521089Medicare PIN