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General NPI Number Information
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NPI Number | 1184351926
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Entity Type | Organization
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Legal Business Name | VIBRANCY VIP MEDCLINIC LLC
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Dates
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Enumeration Date | 08/02/2022
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Last Update Date | 08/02/2022
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Provider Practice Location Address
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Address Line | 4801 ALAMEDA BLVD NE STE A
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City | ALBUQUERQUE
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State | NM
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Zip | 87113-1532
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Country | US
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Telephone | 505-309-3496
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Fax | 505-441-2736
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Provider Business Mailing Address
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Address Line | 4801 ALAMEDA BLVD NE STE A
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City | ALBUQUERQUE
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State | NM
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Zip | 87113-1532
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Country | US
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Telephone | 505-309-3496
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Fax | 505-441-2736
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Authorized Official
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Title or Position | CLINIC MANAGER
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Name | SONJA MAILMAN
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Credential |
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Telephone | 505-309-3496
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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