Healthcare Provider Details

I. General information

NPI: 1063652535
Provider Name (Legal Business Name): EJS CONSTRUCTION AND DEVELOPMENT, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2009
Last Update Date: 02/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 MANCHESTER PL NW
ALBUQUERQUE NM
87107-3091
US

IV. Provider business mailing address

2120 MANCHESTER PL NW
ALBUQUERQUE NM
87107-3091
US

V. Phone/Fax

Practice location:
  • Phone: 505-249-1940
  • Fax: 505-344-8121
Mailing address:
  • Phone: 505-249-1940
  • Fax: 505-344-8121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number352675
License Number StateNM

VIII. Authorized Official

Name: ERNEST J SANTISTEVAN
Title or Position: ENTREPRENEUR
Credential:
Phone: 505-249-1940