Provider Demographics
NPI:1023427796
Name:MARANLLC
Entity type:Organization
Organization Name:MARANLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHISICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREI
Authorized Official - Middle Name:V
Authorized Official - Last Name:MARCHENKO
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:505-234-1040
Mailing Address - Street 1:10401 MONTGOMERY PKWY NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3876
Mailing Address - Country:US
Mailing Address - Phone:505-234-1040
Mailing Address - Fax:505-293-7183
Practice Address - Street 1:10401 MONTGOMERY PKWY NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3876
Practice Address - Country:US
Practice Address - Phone:505-234-1040
Practice Address - Fax:505-293-7183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP01745261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care