Healthcare Provider Details

I. General information

NPI: 1356772321
Provider Name (Legal Business Name): PG AND S, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2013
Last Update Date: 12/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10517 CAROL PL NE
ALBUQUERQUE NM
87112-5305
US

IV. Provider business mailing address

10517 CAROL PL NE
ALBUQUERQUE NM
87112-5305
US

V. Phone/Fax

Practice location:
  • Phone: 505-903-1671
  • Fax:
Mailing address:
  • Phone: 505-903-1671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number4796330
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number4796330
License Number StateNM

VIII. Authorized Official

Name: MS. MBAEMBER JOYCE DAVID-WUAM
Title or Position: CEO/OWNER
Credential: MPH
Phone: 505-903-1671