Healthcare Provider Details

I. General information

NPI: 1912960576
Provider Name (Legal Business Name): NMVAHCS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 MADEIRA DR SE 1501 SAN PEDRO DR. SE
ALBUQUERQUE NM
87108-3615
US

IV. Provider business mailing address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax: 505-256-5493
Mailing address:
  • Phone: 505-265-1711
  • Fax: 505-256-5493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2615
License Number StateNM

VIII. Authorized Official

Name: SAHREEM A LUERGAN
Title or Position: PHYSICAL THERAPIST
Credential: P.T.
Phone: 505-265-1711