Healthcare Provider Details

I. General information

NPI: 1407652233
Provider Name (Legal Business Name): VLC III, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2025
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 GALISTEO ST
SANTA FE NM
87505-2143
US

IV. Provider business mailing address

5658 1/2 MAIN ST
SYLVANIA OH
43560-1928
US

V. Phone/Fax

Practice location:
  • Phone: 505-477-1138
  • Fax: 575-288-2211
Mailing address:
  • Phone: 505-365-3202
  • Fax: 419-243-0221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: LUCAS J NACHTRAB
Title or Position: PRESIDENT
Credential:
Phone: 505-365-3202