Healthcare Provider Details

I. General information

NPI: 1962787812
Provider Name (Legal Business Name): FIESTA PARK HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2011
Last Update Date: 12/10/2014
Certification Date:
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: 505-998-1551
  • Fax:
Mailing address:
  • Phone: 505-998-1551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. ROBERT JEREMY MARTIN
Title or Position: CEO
Credential:
Phone: 505-652-1985