Healthcare Provider Details

I. General information

NPI: 1336489772
Provider Name (Legal Business Name): MAKING LIFE SMILE ORGANIZATION, CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2013
Last Update Date: 03/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 WELLESLEY CT NE APT 1
ALBUQUERQUE NM
87107-4455
US

IV. Provider business mailing address

3301 WELLESLEY CT NE APT 1
ALBUQUERQUE NM
87107-4455
US

V. Phone/Fax

Practice location:
  • Phone: 505-312-8815
  • Fax: 505-212-0991
Mailing address:
  • Phone: 505-312-8815
  • Fax: 505-212-0991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. SHEILA ANNETTE PARKER
Title or Position: PRESIDENT/OWNER
Credential: CPA
Phone: 505-312-8815