1033770904 NPI number — LIFE RE-CREATED LLC

Table of content: SARA ELIZABETH LIBBY GLAPA APNP (NPI 1750514873)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033770904 NPI number — LIFE RE-CREATED LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFE RE-CREATED LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033770904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8946
Provider Second Line Business Mailing Address:
C/O CATHRYN GLENDAY
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87198-8946
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-369-6756
Provider Business Mailing Address Fax Number:
505-393-5201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3939 SAN PEDRO DR. NE
Provider Second Line Business Practice Location Address:
BLD C, STE 8
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-369-6756
Provider Business Practice Location Address Fax Number:
505-393-5201
Provider Enumeration Date:
06/21/2019

Additional Information

Authorized Official

Authorized Official Last Name:
GLENDAY
Authorized Official First Name:
CATHRYN
Authorized Official Middle Name:
ANA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
505-369-6756

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9673365 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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