Provider Demographics
NPI:1851660229
Name:SOUTHWEST VASCULAR, LLC
Entity Type:Organization
Organization Name:SOUTHWEST VASCULAR, LLC
Other - Org Name:SOUTHWEST VASCULAR & VEIN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VEDAMANIKAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-636-2388
Mailing Address - Street 1:PO BOX 2707
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88004-2707
Mailing Address - Country:US
Mailing Address - Phone:575-526-3625
Mailing Address - Fax:575-526-7112
Practice Address - Street 1:909 N DATE ST
Practice Address - Street 2:SUITE B
Practice Address - City:T OR C
Practice Address - State:NM
Practice Address - Zip Code:87901-1747
Practice Address - Country:US
Practice Address - Phone:575-636-2388
Practice Address - Fax:575-680-2591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-14
Last Update Date:2017-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2011-0121207Q00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty