Healthcare Provider Details

I. General information

NPI: 1639523699
Provider Name (Legal Business Name): STUDIO VSC PREVENTIVE HEALTH MAINTENANCE OF THE FEET
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2016
Last Update Date: 04/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 8TH ST SW
ALBUQUERQUE NM
87102-4006
US

IV. Provider business mailing address

910 8TH ST SW
ALBUQUERQUE NM
87102-4006
US

V. Phone/Fax

Practice location:
  • Phone: 505-516-9869
  • Fax:
Mailing address:
  • Phone: 505-516-9869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberCO039083
License Number StateNM

VIII. Authorized Official

Name: VIRGINIA S CHAVIRA
Title or Position: REGISTERED COSMETOLOGIST
Credential: R.C
Phone: 505-516-9869