Provider Demographics
NPI:1952585184
Name:BRAZOS VALLEY CARDIO RESPIRATORY
Entity Type:Organization
Organization Name:BRAZOS VALLEY CARDIO RESPIRATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:RRT/RCP
Authorized Official - Phone:575-257-5083
Mailing Address - Street 1:141-A MESCALERO TR.
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345
Mailing Address - Country:US
Mailing Address - Phone:575-257-5083
Mailing Address - Fax:575-257-5083
Practice Address - Street 1:141-A MESCALERO TR.
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345
Practice Address - Country:US
Practice Address - Phone:575-257-5083
Practice Address - Fax:575-257-5083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX56124293D00000X
TX0059159332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0111049-01Medicaid
TX0111049-01Medicaid