Basic Information
| Provider Information | |||||||||
| NPI: | 1174559082 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOR-LEA HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TATUM MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 NORTH MAIN | ||||||||
| Address2: | |||||||||
| City: | LOVINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882602813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753966611 | ||||||||
| FaxNumber: | 5753961454 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 N MAIN | ||||||||
| Address2: | |||||||||
| City: | TATUM | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882679802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753982111 | ||||||||
| FaxNumber: | 5753986112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 05/01/2014 | ||||||||
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| AuthorizedOfficialLastName: | SHAW | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 5753966611 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 6260 | NM | N | Ambulatory Health Care Facilities | Clinic/Center | 261QR1300X | 6260 | NM | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 45260 | 05 | NM | MEDICAID |