West Valley Clinic, LLC
Organization Active NPI Clinic/Center · Canutillo, TX
NPI 1003186248 · NPPES record last updated Sep 10, 2020
Key facts
- NPI
- 1003186248
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Clinic/Center 261Q00000X
- License
- H2185 (TX)
- Legal business name
- WEST VALLEY CLINIC, LLC
- Practice address
- 6898 Doniphan Drive
Canutillo, TX 79835-2076 - Phone
- (915) 877-3151
- Fax
- (915) 877-5346
- NPI assigned
- Jan 5, 2012
- Organization subpart
- No
Authorized official
- Name
- Sam T Tyson, M.D.
- Title
- Coo/Manager
- Phone
- (915) 877-3151
Practitioners 2
-
Sam Tilden Tyson, M.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in TX
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20201026000352 | TX | Part B Supplier - Clinic/Group Practice | 0840610143 |
Receives reassigned benefits from 1 practitioner Practice locations: Canutillo, TX |
National Provider Directory
Locations
6898 Doniphan Dr
#B
Canutillo, TX 79835
Phone (915) 877-3151
6898 Doniphan Dr
Canutillo, TX 79835
Phone (915) 877-3124
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinic/Center | 261Q00000X | H2185 | TX | Yes |
Addresses
Primary practice location
6898 Doniphan Drive
Canutillo, TX 79835-2076
Mailing address
6898 Doniphan Drive
P.O Box 2076
Canutillo, TX 79835-2076
Phone (915) 877-3151
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 138392907 | Medicaid | TX |
Other providers in Canutillo, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 10, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.