Healthcare Provider Details

I. General information

NPI: 1477095966
Provider Name (Legal Business Name): SURGICAL ONCOLOGY AND GASTROINTESTINAL SURGERY CONSULTANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2016
Last Update Date: 11/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 UPTOWN BLVD NE STE 600
ALBUQUERQUE NM
87110-4163
US

IV. Provider business mailing address

6100 UPTOWN BLVD NE STE 600
ALBUQUERQUE NM
87110-4163
US

V. Phone/Fax

Practice location:
  • Phone: 505-200-3808
  • Fax: 505-200-3807
Mailing address:
  • Phone: 505-200-3808
  • Fax: 505-200-3807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD0825
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2001214
License Number StateNM

VIII. Authorized Official

Name: MONICA LIPIZ-VALLEJOS
Title or Position: CLINICAL ADMINISTRATIVE DIRECTOR
Credential:
Phone: 505-200-3808