Provider Demographics
NPI:1750143616
Name:CHAVEZ, HERMAN EUGENE
Entity type:Individual
Prefix:
First Name:HERMAN
Middle Name:EUGENE
Last Name:CHAVEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2495 PARKLANE DR
Mailing Address - Street 2:
Mailing Address - City:BOSQUE FARMS
Mailing Address - State:NM
Mailing Address - Zip Code:87068-9397
Mailing Address - Country:US
Mailing Address - Phone:505-463-8207
Mailing Address - Fax:
Practice Address - Street 1:7450 SKYHAWK LP
Practice Address - Street 2:
Practice Address - City:NEWCOMB
Practice Address - State:NM
Practice Address - Zip Code:87455
Practice Address - Country:US
Practice Address - Phone:505-463-8207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM506289451347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle