Healthcare Provider Details

I. General information

NPI: 1932600673
Provider Name (Legal Business Name): MEDCLUB VIP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 02/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4325 CARLISLE BLVD NE
ALBUQUERQUE NM
87107-4810
US

IV. Provider business mailing address

4325 CARLISLE BLVD NE
ALBUQUERQUE NM
87107-4810
US

V. Phone/Fax

Practice location:
  • Phone: 505-433-4007
  • Fax: 505-433-4068
Mailing address:
  • Phone: 505-433-4007
  • Fax: 505-433-4068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RICK CARDENAS
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 505-433-4007