Healthcare Provider Details

I. General information

NPI: 1679996334
Provider Name (Legal Business Name): ADA ELISA VARGAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2014
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 PERKINS DR
LAS CRUCES NM
88005-3248
US

IV. Provider business mailing address

301 PERKINS DR
LAS CRUCES NM
88005-3248
US

V. Phone/Fax

Practice location:
  • Phone: 575-526-6682
  • Fax: 575-523-7254
Mailing address:
  • Phone: 575-526-6682
  • Fax: 575-523-7254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-06871
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: