Healthcare Provider Details

I. General information

NPI: 1396799110
Provider Name (Legal Business Name): MILAGRO VEIN SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 09/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490B W ZIA ROAD SUITE A
SANTA FE NM
87505
US

IV. Provider business mailing address

PO BOX 13385
SCOTTSDALE AZ
85267-3385
US

V. Phone/Fax

Practice location:
  • Phone: 505-995-8346
  • Fax: 505-995-8345
Mailing address:
  • Phone: 480-609-9300
  • Fax: 480-609-9350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH M. SMITH III
Title or Position: PARTNER
Credential: MD
Phone: 505-995-8346