1750448056 NPI number — LA VIDA FELICIDAD, INC.

Table of content: (NPI 1750448056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750448056 NPI number — LA VIDA FELICIDAD, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LA VIDA FELICIDAD, INC.
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:
1750448056
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2040
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS LUNAS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87031-2040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-565-1614
Provider Business Mailing Address Fax Number:
505-565-1608

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
530 SUN RANCH VILLAGE LOOP SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS LUNAS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87031-4809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-565-1614
Provider Business Practice Location Address Fax Number:
505-565-1608
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MONDRAGON
Authorized Official First Name:
MARTIN
Authorized Official Middle Name:
ISAIAS
Authorized Official Title or Position:
ASSOCIATE DIRECTOR
Authorized Official Telephone Number:
505-565-1614

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X , with the licence number:  5604 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Z7498 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: D1246 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: E7184 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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