Provider Demographics
NPI:1669780904
Name:WOFFORD MEDICAL PRACTICE LLC
Entity type:Organization
Organization Name:WOFFORD MEDICAL PRACTICE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:BERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:WOFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-226-2273
Mailing Address - Street 1:205 W BOUTZ RD
Mailing Address - Street 2:BLDG 1
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3259
Mailing Address - Country:US
Mailing Address - Phone:575-532-7000
Mailing Address - Fax:575-532-7006
Practice Address - Street 1:421 S AVE C
Practice Address - Street 2:STE D
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6328
Practice Address - Country:US
Practice Address - Phone:575-226-2273
Practice Address - Fax:575-226-2378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-21
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty