Healthcare Provider Details

I. General information

NPI: 1447442512
Provider Name (Legal Business Name): ST. JOHN HEALTHCARE AND REHABILITATION CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2216 LESTER DR NE
ALBUQUERQUE NM
87112-2607
US

IV. Provider business mailing address

2216 LESTER DR NE
ALBUQUERQUE NM
87112-2607
US

V. Phone/Fax

Practice location:
  • Phone: 505-296-4808
  • Fax: 505-293-0398
Mailing address:
  • Phone: 505-296-4808
  • Fax: 505-293-0398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1065
License Number StateNM

VIII. Authorized Official

Name: MICHAEL T. BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4752