Healthcare Provider Details

I. General information

NPI: 1619137650
Provider Name (Legal Business Name): ALBUQUERQUE GRAND SENIOR LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 06/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 TIJERAS AVE NE
ALBUQUERQUE NM
87106-4518
US

IV. Provider business mailing address

1501 TIJERAS AVE NE
ALBUQUERQUE NM
87106-4518
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-1972
  • Fax: 505-842-1655
Mailing address:
  • Phone: 505-842-1972
  • Fax: 505-842-1655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number5544
License Number StateNM

VIII. Authorized Official

Name: MRS. BARBARA L FERGUSON
Title or Position: ADMINISTRATOR
Credential: R.N.
Phone: 505-842-1972