Healthcare Provider Details

I. General information

NPI: 1245454073
Provider Name (Legal Business Name): VASCULAR DIAGNOSTIC LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 12/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 FOOTHILLS RD. #3
LAS CRUCES NM
88011-8268
US

IV. Provider business mailing address

P.O. BOX 6366
LAS CRUCES NM
88006-6366
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-5511
  • Fax: 575-522-0825
Mailing address:
  • Phone: 575-522-5511
  • Fax: 575-522-0825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MRS. RITA POLSKY
Title or Position: ADMINISTRATOR
Credential:
Phone: 575-635-7145