Healthcare Provider Details

I. General information

NPI: 1700078870
Provider Name (Legal Business Name): ST. THERESA 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

7900 CONSTITUTION AVE NE
ALBUQUERQUE NM
87110-7513
US

IV. Provider business mailing address

7900 CONSTITUTION AVE NE
ALBUQUERQUE NM
87110-7513
US

V. Phone/Fax

Practice location:
  • Phone: 505-296-5565
  • Fax: 505-296-6659
Mailing address:
  • Phone: 505-296-5565
  • Fax: 505-296-6659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1064
License Number StateNM

VIII. Authorized Official

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