MEDICARE: MVI SURGERY CENTER,LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1699159053
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MVI SURGERY CENTER,LLC

Provider Business Mailing Address
First Line	:	2920 STANFORD DR NE
Second Line	:	SUITE C
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-1807
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1720 WYOMING BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-3855
Country	:	US
Telephone Number	:	505-872-0450
Fax Number	:

Authorized Official
Title or Position	:	CONSULTANT
Name	:	JARED LEGER
Credential	:
Telephone Number	:	337-274-6549

Provider Enumeration Date	:	07/16/2015
Last Update Date	:	07/16/2015

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