Healthcare Provider Details

I. General information

NPI: 1003337247
Provider Name (Legal Business Name): VEGA DIAGNOSTIC & CONSULTING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 06/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 RITO GUICU
SANTA FE NM
87507-4321
US

IV. Provider business mailing address

29 RITO GUICU
SANTA FE NM
87507-4321
US

V. Phone/Fax

Practice location:
  • Phone: 505-235-4002
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number375345
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0123991
License Number StateNM

VIII. Authorized Official

Name: SUN VEGA
Title or Position: MANAGING PARTNER
Credential: MBA
Phone: 505-235-4002