Healthcare Provider Details

I. General information

NPI: 1366631780
Provider Name (Legal Business Name): SUSAN'S LEGACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 05/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 MOUNTAIN RD NE SUITE 200
ALBUQUERQUE NM
87110
US

IV. Provider business mailing address

11000 SPAIN NE
ALBUQUERQUE NM
87111
US

V. Phone/Fax

Practice location:
  • Phone: 505-843-8450
  • Fax: 505-843-8449
Mailing address:
  • Phone: 505-843-8450
  • Fax: 505-843-8449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number0071091
License Number StateNM

VIII. Authorized Official

Name: DR. KATHRYN WEIL
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D.
Phone: 505-843-8450