Healthcare Provider Details

I. General information

NPI: 1285801498
Provider Name (Legal Business Name): SOUTHWEST RESIDENTIAL LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1606 ROMA AVE NE
ALBUQUERQUE NM
87106-4515
US

IV. Provider business mailing address

5109 MENAUL BLVD NE
ALBUQUERQUE NM
87110-3045
US

V. Phone/Fax

Practice location:
  • Phone: 505-888-6200
  • Fax:
Mailing address:
  • Phone: 505-888-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: DELORES MORENO
Title or Position: PARTNER
Credential:
Phone: 505-888-6200