Healthcare Provider Details

I. General information

NPI: 1477710689
Provider Name (Legal Business Name): THE VICTORIAN HOUSE SLEEP CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2008
Last Update Date: 05/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4036 CORRALES RD
CORRALES NM
87048-9308
US

IV. Provider business mailing address

5109 MENAUL BLVD NE
ALBUQUERQUE NM
87110-3045
US

V. Phone/Fax

Practice location:
  • Phone: 505-319-9617
  • Fax:
Mailing address:
  • Phone: 505-888-6200
  • Fax: 505-888-6202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PEDRO MORENO SR.
Title or Position: OWNER
Credential:
Phone: 505-319-9617