Healthcare Provider Details

I. General information

NPI: 1427456458
Provider Name (Legal Business Name): THE COMMUNITY LIGHTHOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2014
Last Update Date: 10/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 CANDELARIA RD NE STE B
ALBUQUERQUE NM
87107-1965
US

IV. Provider business mailing address

3301 CANDELARIA RD NE STE B
ALBUQUERQUE NM
87107-1965
US

V. Phone/Fax

Practice location:
  • Phone: 505-273-6300
  • Fax: 505-265-7860
Mailing address:
  • Phone: 505-273-6300
  • Fax: 505-265-7860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM08822
License Number StateNM

VIII. Authorized Official

Name: MARIA MENDEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-273-6300