Provider Demographics
NPI:1003337247
Name:VEGA DIAGNOSTIC & CONSULTING SERVICES, LLC
Entity Type:Organization
Organization Name:VEGA DIAGNOSTIC & CONSULTING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SUN
Authorized Official - Middle Name:
Authorized Official - Last Name:VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:505-235-4002
Mailing Address - Street 1:29 RITO GUICU
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-4321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29 RITO GUICU
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-4321
Practice Address - Country:US
Practice Address - Phone:505-235-4002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0123991101YP2500X
NM375345103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty