Provider Demographics
NPI:1659607760
Name:NORTHERN NM VASCULAR LAB
Entity Type:Organization
Organization Name:NORTHERN NM VASCULAR LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:E
Authorized Official - Last Name:WALSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-982-3814
Mailing Address - Street 1:531 HARKLE RD
Mailing Address - Street 2:SUITE A-2
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4753
Mailing Address - Country:US
Mailing Address - Phone:505-982-3814
Mailing Address - Fax:505-983-1899
Practice Address - Street 1:7555 ENCHANTED HLS DR NE
Practice Address - Street 2:SUITE 210
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-8625
Practice Address - Country:US
Practice Address - Phone:505-771-9001
Practice Address - Fax:505-771-7074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-23
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM54528Medicaid
NM2440066Medicare PIN