Healthcare Provider Details

I. General information

NPI: 1023373370
Provider Name (Legal Business Name): MARIPOSA SENIOR CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3811 ACADEMY PKWY S NE
ALBUQUERQUE NM
87108
US

IV. Provider business mailing address

3811 ACADEMY PKWY S NE
ALBUQUERQUE NM
87109
US

V. Phone/Fax

Practice location:
  • Phone: 505-234-1744
  • Fax: 505-234-1733
Mailing address:
  • Phone: 505-234-1744
  • Fax: 505-234-1733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number1T3404
License Number StateNM

VIII. Authorized Official

Name: MR. JASON MCDERMOTT
Title or Position: PRESIDENT
Credential:
Phone: 505-234-1744