Healthcare Provider Details

I. General information

NPI: 1154047751
Provider Name (Legal Business Name): MAYBERRY SENIOR SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2022
Last Update Date: 10/21/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5528 EUBANK BLVD NE STE 1
ALBUQUERQUE NM
87111-1500
US

IV. Provider business mailing address

5528 EUBANK BLVD NE STE 1
ALBUQUERQUE NM
87111-1500
US

V. Phone/Fax

Practice location:
  • Phone: 505-271-0000
  • Fax: 505-212-4282
Mailing address:
  • Phone: 505-271-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSICA LAGER
Title or Position: CEO
Credential:
Phone: 505-271-0000