Healthcare Provider Details

I. General information

NPI: 1972916153
Provider Name (Legal Business Name): A NEW LIFE STYLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2014
Last Update Date: 06/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532 ADAMS ST NE
ALBUQUERQUE NM
87108-1229
US

IV. Provider business mailing address

532 ADAMS ST NE
ALBUQUERQUE NM
87108-1229
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-9393
  • Fax: 505-266-6130
Mailing address:
  • Phone: 505-265-9393
  • Fax: 505-266-6130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: ARCHIE GRINE
Title or Position: DIRECTOR/CEO
Credential: LPCC
Phone: 505-265-9393