Healthcare Provider Details

I. General information

NPI: 1982011631
Provider Name (Legal Business Name): LUNA VISTA HOME HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2014
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2116 VISTA OESTE NW #1A
ALBUQUERQUE NM
87120-4340
US

IV. Provider business mailing address

2116 VISTA OESTE NW #1A
ALBUQUERQUE NM
87120-4340
US

V. Phone/Fax

Practice location:
  • Phone: 505-440-8316
  • Fax: 505-288-3494
Mailing address:
  • Phone: 505-440-8316
  • Fax: 505-288-3494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JAMIE GONZALES
Title or Position: ADMINISTRATOR / OWNER
Credential:
Phone: 505-977-3131