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1194772939

NPI Code Detail

MEDICARE: PEAK MEDICAL ASSISTED LIVING, LLC

MEDICARE: PEAK MEDICAL ASSISTED LIVING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	5788	NM
2	311500000X	Alzheimer Center (Dementia Center)	5789	NM
3	314000000X	Skilled Nursing Facility	5841	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PROVA41670	OTHER	NM	MOLINA
2	M156	OTHER	NM	BC/BS OF NM

General Provider Information

NPI Number	:	1194772939
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEAK MEDICAL ASSISTED LIVING, LLC

Provider Business Mailing Address
First Line	:	2884 N ROADRUNNER PKWY
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-0853
Country	:	US
Telephone Number	:	575-522-1110
Fax Number	:

Provider Business Practice Location Address
First Line	:	2884 N ROADRUNNER PKWY
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-0853
Country	:	US
Telephone Number	:	575-522-1110
Fax Number	:

Authorized Official
Title or Position	:	ASSISTANT SECRETARY
Name	:	MICHAEL BERG
Credential	:
Telephone Number	:	505-468-4752

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	11/27/2018

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Directions to “PEAK MEDICAL ASSISTED LIVING, LLC ” Practice Location

Language	Start Address	Practice Location

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