Healthcare Provider Details

I. General information

NPI: 1326933771
Provider Name (Legal Business Name): MR. ATENOGENES VAZQUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2025
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11212 MIRAVISTA PL SE
ALBUQUERQUE NM
87123
US

IV. Provider business mailing address

11212 MIRAVISTA PLACE SE
ALBUQUERQUE NM
87123
US

V. Phone/Fax

Practice location:
  • Phone: 505-373-9285
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number2126
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: