Healthcare Provider Details

I. General information

NPI: 1972690154
Provider Name (Legal Business Name): CASA ARENA BLANCA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2006
Last Update Date: 05/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 MOONGLOW AVE
ALAMOGORDO NM
88310-3339
US

IV. Provider business mailing address

920 RIDGEBROOK RD
SPARKS MD
21152-9390
US

V. Phone/Fax

Practice location:
  • Phone: 505-434-4510
  • Fax: 505-434-4513
Mailing address:
  • Phone: 410-773-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: TAMI KLINEDINST
Title or Position: PRESIDENT
Credential:
Phone: 505-434-4510