1831354059 NPI number — LA BUENA VIDA, INC.

Table of content: (NPI 1831354059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831354059 NPI number — LA BUENA VIDA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LA BUENA VIDA, 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:
LA BUENA VIDA, INC. - RIO RANCHO OFFICE
Provider Other Organization Name Type Code:
5
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:
1831354059
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1147
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERNALILLO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87004-1147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-867-2383
Provider Business Mailing Address Fax Number:
505-867-2383

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 21ST ST SE
Provider Second Line Business Practice Location Address:
SUITES 8 & 10
Provider Business Practice Location Address City Name:
RIO RANCHO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87124-4030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-994-4040
Provider Business Practice Location Address Fax Number:
505-867-2383
Provider Enumeration Date:
07/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MALNAR
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
505-867-2383

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  3034 , 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: E7034 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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