Healthcare Provider Details

I. General information

NPI: 1205122769
Provider Name (Legal Business Name): DANA PAINE ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 MADEIRA DR NE
ALBUQUERQUE NM
87108-1424
US

IV. Provider business mailing address

920 MADEIRA DR NE
ALBUQUERQUE NM
87108-1424
US

V. Phone/Fax

Practice location:
  • Phone: 505-266-8168
  • Fax: 505-266-8168
Mailing address:
  • Phone: 505-266-8168
  • Fax: 505-266-8168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0095841
License Number StateNM

VIII. Authorized Official

Name: DANA JOSEPH PAINE
Title or Position: DIRECTOR
Credential:
Phone: 505-266-8168