1417600230 NPI number — CARLSBAD VEIN AND VASCULAR CENTER OF NEW MEXICO

Table of content: (NPI 1417600230)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417600230 NPI number — CARLSBAD VEIN AND VASCULAR CENTER OF NEW MEXICO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARLSBAD VEIN AND VASCULAR CENTER OF NEW MEXICO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417600230
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31869
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-0180
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-941-4400
Provider Business Mailing Address Fax Number:
888-572-7765

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1619 SKYLINE CIR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARLSBAD
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88220-9842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-941-4400
Provider Business Practice Location Address Fax Number:
833-620-2406
Provider Enumeration Date:
02/01/2022

Additional Information

Authorized Official

Authorized Official Last Name:
WACKER
Authorized Official First Name:
TAMI
Authorized Official Middle Name:
L
Authorized Official Title or Position:
REVENUE CYCLE MANAGER
Authorized Official Telephone Number:
575-941-4400

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 96476371 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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