Healthcare Provider Details

I. General information

NPI: 1154665628
Provider Name (Legal Business Name): NM VA HEALTH CARE SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2012
Last Update Date: 11/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 LA JUNTA RD SW
ALBUQUERQUE NM
87105-5643
US

IV. Provider business mailing address

3121 LA JUNTA RD SW
ALBUQUERQUE NM
87105-5643
US

V. Phone/Fax

Practice location:
  • Phone: 505-710-9505
  • Fax:
Mailing address:
  • Phone: 505-710-9505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ROGER CRAIG BUSTAMANTE
Title or Position: LPN
Credential:
Phone: 505-710-9505