Provider Demographics
NPI:1932600673
Name:MEDCLUB VIP LLC
Entity Type:Organization
Organization Name:MEDCLUB VIP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:CARDENAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-433-4007
Mailing Address - Street 1:4325 CARLISLE BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-4810
Mailing Address - Country:US
Mailing Address - Phone:505-433-4007
Mailing Address - Fax:505-433-4068
Practice Address - Street 1:4325 CARLISLE BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4810
Practice Address - Country:US
Practice Address - Phone:505-433-4007
Practice Address - Fax:505-433-4068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-27
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty