Healthcare Provider Details

I. General information

NPI: 1285921569
Provider Name (Legal Business Name): TRANSITIONAL LIVING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 07/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 DOMINGO RD NE
ALBUQUERQUE NM
87108-1610
US

IV. Provider business mailing address

5601 DOMINGO RD NE
ALBUQUERQUE NM
87108-1610
US

V. Phone/Fax

Practice location:
  • Phone: 505-268-5295
  • Fax:
Mailing address:
  • Phone: 505-268-5295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number105341
License Number StateNM

VIII. Authorized Official

Name: MR. GARY B JACKSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 505-268-5295