Healthcare Provider Details

I. General information

NPI: 1972500957
Provider Name (Legal Business Name): LA VIDA LLENA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10501 LAGRIMA DE ORO RD NE
ALBUQUERQUE NM
87111-3737
US

IV. Provider business mailing address

10501 LAGRIMA DE ORO RD NE
ALBUQUERQUE NM
87111-3737
US

V. Phone/Fax

Practice location:
  • Phone: 505-296-6700
  • Fax: 505-292-8843
Mailing address:
  • Phone: 505-923-4001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5061
License Number StateNM

VIII. Authorized Official

Name: KONRAD VAN BAALEN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 505-359-1978