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General NPI Number Information
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NPI Number | 1659607760
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Entity Type | Organization
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Legal Business Name | NORTHERN NM VASCULAR LAB
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Dates
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Enumeration Date | 10/23/2009
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Last Update Date | 10/23/2009
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Provider Practice Location Address
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Address Line | 7555 ENCHANTED HLS DR NE SUITE 210
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City | RIO RANCHO
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State | NM
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Zip | 87144-8625
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Country | US
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Telephone | 505-771-9001
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Fax | 505-771-7074
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Provider Business Mailing Address
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Address Line | 531 HARKLE RD SUITE A-2
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City | SANTA FE
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State | NM
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Zip | 87505-4753
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Country | US
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Telephone | 505-982-3814
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Fax | 505-983-1899
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Authorized Official
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Title or Position | OWNER
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Name | MR. PAUL E. WALSKY
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Credential | M.D.
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Telephone | 505-982-3814
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State | NM
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