Healthcare Provider Details

I. General information

NPI: 1720470123
Provider Name (Legal Business Name): FRIENDSHIP GARDENSALF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2015
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 MORRIS ST NE
ALBUQUERQUE NM
87112-3125
US

IV. Provider business mailing address

1909 MORRIS ST NE
ALBUQUERQUE NM
87112-3125
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-1426
  • Fax: 505-503-6978
Mailing address:
  • Phone: 505-298-1426
  • Fax: 505-503-6978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number2201
License Number StateNM

VIII. Authorized Official

Name: MS. LILY E STAFFORD
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 505-917-3553