Healthcare Provider Details

I. General information

NPI: 1699427344
Provider Name (Legal Business Name): MAKING AN IMPACT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2022
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8601 GOLF COURSE RD NW
ALBUQUERQUE NM
87114-5775
US

IV. Provider business mailing address

8601 GOLF COURSE RD NW
ALBUQUERQUE NM
87114-5775
US

V. Phone/Fax

Practice location:
  • Phone: 719-651-7585
  • Fax:
Mailing address:
  • Phone: 719-651-7585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PAUL COVELLI
Title or Position: OWNER
Credential:
Phone: 719-651-7584