Healthcare Provider Details

I. General information

NPI: 1922646595
Provider Name (Legal Business Name): PSYCHOGENESIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2019
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 EUBANK BLVD NE STE 18
ALBUQUERQUE NM
87111-3427
US

IV. Provider business mailing address

PO BOX 93274
ALBUQUERQUE NM
87199-3274
US

V. Phone/Fax

Practice location:
  • Phone: 505-585-3744
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JAVIER VERA
Title or Position: OWNER
Credential: MD
Phone: 505-585-3744