Healthcare Provider Details

I. General information

NPI: 1184351926
Provider Name (Legal Business Name): VIBRANCY VIP MEDCLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 ALAMEDA BLVD NE STE A
ALBUQUERQUE NM
87113-1532
US

IV. Provider business mailing address

4801 ALAMEDA BLVD NE STE A
ALBUQUERQUE NM
87113-1532
US

V. Phone/Fax

Practice location:
  • Phone: 505-309-3496
  • Fax: 505-441-2736
Mailing address:
  • Phone: 505-309-3496
  • Fax: 505-441-2736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: SONJA MAILMAN
Title or Position: CLINIC MANAGER
Credential:
Phone: 505-309-3496