Provider Demographics
NPI:1770738999
Name:BASIN OCCUPATIONAL AND URGENT CARE
Entity type:Organization
Organization Name:BASIN OCCUPATIONAL AND URGENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-324-0149
Mailing Address - Street 1:PO BOX 1806
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-1806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1308 E 20TH ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-9022
Practice Address - Country:US
Practice Address - Phone:505-324-0149
Practice Address - Fax:505-327-2197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-02
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care