Healthcare Provider Details

I. General information

NPI: 1518600949
Provider Name (Legal Business Name): FIESTA PARK WELLNESS & REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2022
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8820 HORIZON BLVD NE
ALBUQUERQUE NM
87113-1689
US

IV. Provider business mailing address

8820 HORIZON BLVD NE
ALBUQUERQUE NM
87113-1689
US

V. Phone/Fax

Practice location:
  • Phone: 505-998-9868
  • Fax: 505-944-7090
Mailing address:
  • Phone: 505-998-9868
  • Fax: 505-944-7090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: DAVID GARETZ
Title or Position: CFO
Credential:
Phone: 323-987-5954