Provider Demographics
NPI:1578647301
Name:SANDIA SURGICAL INC
Entity Type:Organization
Organization Name:SANDIA SURGICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-883-2817
Mailing Address - Street 1:6120 SIGNAL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113
Mailing Address - Country:US
Mailing Address - Phone:505-883-2817
Mailing Address - Fax:505-883-2590
Practice Address - Street 1:6120 SIGNAL NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113
Practice Address - Country:US
Practice Address - Phone:505-883-2817
Practice Address - Fax:505-883-2590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMFA0007917332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ1683Medicaid