Healthcare Provider Details

I. General information

NPI: 1053664599
Provider Name (Legal Business Name): LOST CONTINENT ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2012
Last Update Date: 01/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 MONTANO RD NW SUITE 102
ALBUQUERQUE NM
87120-2427
US

IV. Provider business mailing address

PO BOX 2563
CORRALES NM
87048-2563
US

V. Phone/Fax

Practice location:
  • Phone: 505-385-6364
  • Fax:
Mailing address:
  • Phone: 505-385-6364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0069462
License Number StateNM

VIII. Authorized Official

Name: RAYLAH ETLANTUS
Title or Position: OWNER
Credential: LPCC
Phone: 505-385-6364