Healthcare Provider Details

I. General information

NPI: 1285134080
Provider Name (Legal Business Name): DYB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2018
Last Update Date: 02/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7100 CARRIAGE RD NE
ALBUQUERQUE NM
87109-2905
US

IV. Provider business mailing address

7100 CARRIAGE RD NE
ALBUQUERQUE NM
87109-2905
US

V. Phone/Fax

Practice location:
  • Phone: 505-888-4434
  • Fax: 505-293-9899
Mailing address:
  • Phone: 505-888-4434
  • Fax: 505-293-9899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number5855
License Number StateNM

VIII. Authorized Official

Name: MELISSA Y DOOLEY
Title or Position: DIRECTOR
Credential:
Phone: 505-363-8499