Healthcare Provider Details

I. General information

NPI: 1578644415
Provider Name (Legal Business Name): SAGE NEUROSCIENCE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7850 JEFFERSON ST NE STE 300
ALBUQUERQUE NM
87109-4314
US

IV. Provider business mailing address

7850 JEFFERSON ST NE STE 300
ALBUQUERQUE NM
87109-4314
US

V. Phone/Fax

Practice location:
  • Phone: 505-884-1114
  • Fax: 505-359-3010
Mailing address:
  • Phone: 505-884-1114
  • Fax: 505-359-3010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMD2005-0751
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. REUBEN SUTTER
Title or Position: OWNER
Credential: M.D.
Phone: 505-884-1114