Healthcare Provider Details

I. General information

NPI: 1003128349
Provider Name (Legal Business Name): BUENA SUERTE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 04/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

387 LAKE HAVASU AVE S SUITE 102
LAKE HAVASU CITY AZ
86403-9306
US

IV. Provider business mailing address

387 LAKE HAVASU AVE S SUITE 102
LAKE HAVASU CITY AZ
86403-9306
US

V. Phone/Fax

Practice location:
  • Phone: 928-855-0005
  • Fax: 928-855-0075
Mailing address:
  • Phone: 928-855-0005
  • Fax: 928-855-0075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateAZ

VIII. Authorized Official

Name: MR. CHRISTOPHER L GAMBLE
Title or Position: PRESIDENT
Credential:
Phone: 301-639-3822