Healthcare Provider Details

I. General information

NPI: 1003927807
Provider Name (Legal Business Name): LAUREL CANYON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10101 LAGRIMA DE ORO NE
ALBUQUERQUE NM
87111-6022
US

IV. Provider business mailing address

10101 LAGRIMA DE ORO NE
ALBUQUERQUE NM
87111-6022
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-1231
  • Fax: 505-298-2098
Mailing address:
  • Phone: 505-298-1231
  • Fax: 505-298-2098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1043
License Number StateNM

VIII. Authorized Official

Name: MR. ALAN ZAMPINI
Title or Position: MEMBER
Credential:
Phone: 505-304-5152