1316926041 NPI number — LAGUNA RAINBOW CORPORATION

Table of content: (NPI 1316926041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316926041 NPI number — LAGUNA RAINBOW CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAGUNA RAINBOW CORPORATION
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:
LAGUNA RAINBOW NURSING CENTER
Provider Other Organization Name Type Code:
3
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:
1316926041
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 490
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CASA BLANCA
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87007-0490
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-552-6034
Provider Business Mailing Address Fax Number:
505-552-7645

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
I-40, EXIT 108
Provider Second Line Business Practice Location Address:
1/2 MILE SOUTH STATE ROAD 23
Provider Business Practice Location Address City Name:
CASA BLANCA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87007-0490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-552-6034
Provider Business Practice Location Address Fax Number:
505-552-7645
Provider Enumeration Date:
01/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KORETKE
Authorized Official First Name:
MARY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF REIMBURSEMENT
Authorized Official Telephone Number:
303-987-3088

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  5063 , 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: I0365 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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