Healthcare Provider Details

I. General information

NPI: 1659607760
Provider Name (Legal Business Name): NORTHERN NM VASCULAR LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2009
Last Update Date: 10/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7555 ENCHANTED HLS DR NE SUITE 210
RIO RANCHO NM
87144-8625
US

IV. Provider business mailing address

531 HARKLE RD SUITE A-2
SANTA FE NM
87505-4753
US

V. Phone/Fax

Practice location:
  • Phone: 505-771-9001
  • Fax: 505-771-7074
Mailing address:
  • Phone: 505-982-3814
  • Fax: 505-983-1899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateNM

VIII. Authorized Official

Name: MR. PAUL E. WALSKY
Title or Position: OWNER
Credential: M.D.
Phone: 505-982-3814