Healthcare Provider Details

I. General information

NPI: 1013398437
Provider Name (Legal Business Name): INNOVA VEIN AND VASCULAR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MONTGOMERY BLVD NE # B SUITE 100
ALBUQUERQUE NM
87109-1210
US

IV. Provider business mailing address

4600 MONTGOMERY BLVD NE # B SUITE 100
ALBUQUERQUE NM
87109-1210
US

V. Phone/Fax

Practice location:
  • Phone: 719-320-3691
  • Fax:
Mailing address:
  • Phone: 719-320-3691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN E SANCHEZ
Title or Position: CEO
Credential:
Phone: 719-320-3691