Provider Demographics
NPI:1174850291
Name:CLINICA DE LA GLORIA
Entity Type:Organization
Organization Name:CLINICA DE LA GLORIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VIGIL
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:505-242-3335
Mailing Address - Street 1:1720 BRIDGE BLVD SW STE F
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-3182
Mailing Address - Country:US
Mailing Address - Phone:505-242-3335
Mailing Address - Fax:505-242-2700
Practice Address - Street 1:1720 BRIDGE BLVD SW STE F
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-3182
Practice Address - Country:US
Practice Address - Phone:505-242-3335
Practice Address - Fax:505-242-2700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-10
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR11687364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Single Specialty