Healthcare Provider Details

I. General information

NPI: 1083471551
Provider Name (Legal Business Name): LIFE RE-CREATED, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 ALVARADO DR SE
ALBUQUERQUE NM
87108-3624
US

IV. Provider business mailing address

PO BOX 45681
RIO RANCHO NM
87174-5681
US

V. Phone/Fax

Practice location:
  • Phone: 505-264-4082
  • Fax: 833-964-0176
Mailing address:
  • Phone: 505-226-1960
  • Fax: 505-672-7769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: CATHRYN GLENDAY
Title or Position: OWNER
Credential:
Phone: 505-264-4082