Healthcare Provider Details

I. General information

NPI: 1689969958
Provider Name (Legal Business Name): NEW MEXICO MEDICAL DIAGNOSTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 06/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2004 ARENAL RD SW
ALBUQUERQUE NM
87105-4043
US

IV. Provider business mailing address

2004 ARENAL RD SW
ALBUQUERQUE NM
87105-4043
US

V. Phone/Fax

Practice location:
  • Phone: 505-553-6847
  • Fax: 150-587-7138
Mailing address:
  • Phone: 505-553-6847
  • Fax: 150-587-7138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246XC2903X
TaxonomyVascular Specialist/Technologist Cardiovascular
License NumberARDMS123249
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License NumberARDMS123249
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code2471V0106X
TaxonomyVascular-Interventional Technology Radiologic Technologist
License NumberARDMS123249
License Number StateNM

VIII. Authorized Official

Name: MR. ANGEL RICK MARTINEZ I
Title or Position: OWNER
Credential: RVT
Phone: 505-553-6847