1982863999 NPI number — BUENA VIDA PHYSICAL THERAPY AND WELLNESS LLC

Table of content: (NPI 1982863999)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982863999 NPI number — BUENA VIDA PHYSICAL THERAPY AND WELLNESS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BUENA VIDA PHYSICAL THERAPY AND WELLNESS 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:
1982863999
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 E LINCOLN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87701-4502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-425-2998
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 E LINCOLN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87701-4502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-425-2998
Provider Business Practice Location Address Fax Number:
505-425-2897
Provider Enumeration Date:
06/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BURCIAGA
Authorized Official First Name:
STELLA
Authorized Official Middle Name:
JEANNE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
505-718-8309

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  3283 , 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: 36072842 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com