Healthcare Provider Details

I. General information

NPI: 1720243173
Provider Name (Legal Business Name): HOUSE OF HEARTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2008
Last Update Date: 07/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2612 CHELWOOD PARK BLVD NE
ALBUQUERQUE NM
87112-1978
US

IV. Provider business mailing address

2612 CHELWOOD PARK BLVD NE
ALBUQUERQUE NM
87112-1978
US

V. Phone/Fax

Practice location:
  • Phone: 505-506-7901
  • Fax: 505-294-1278
Mailing address:
  • Phone: 505-506-7901
  • Fax: 505-294-1278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberFA0080936
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberFA0080936
License Number StateNM

VIII. Authorized Official

Name: WILLIAM S KEENAN
Title or Position: DIRECTOR
Credential:
Phone: 505-977-2074