Provider Demographics
NPI:1417600230
Name:CARLSBAD VEIN AND VASCULAR CENTER OF NEW MEXICO
Entity type:Organization
Organization Name:CARLSBAD VEIN AND VASCULAR CENTER OF NEW MEXICO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REVENUE CYCLE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMI
Authorized Official - Middle Name:L
Authorized Official - Last Name:WACKER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LNHA
Authorized Official - Phone:575-941-4400
Mailing Address - Street 1:PO BOX 31869
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-0180
Mailing Address - Country:US
Mailing Address - Phone:575-941-4400
Mailing Address - Fax:888-572-7765
Practice Address - Street 1:1619 SKYLINE CIR STE A
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-9842
Practice Address - Country:US
Practice Address - Phone:575-941-4400
Practice Address - Fax:833-620-2406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-01
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM96476371Medicaid