Healthcare Provider Details

I. General information

NPI: 1386676856
Provider Name (Legal Business Name): LA BUENA VIDA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

872 CAMINO DEL PUEBLO
BERNALILLO NM
87004
US

IV. Provider business mailing address

PO BOX 1147
BERNALILLO NM
87004-1147
US

V. Phone/Fax

Practice location:
  • Phone: 505-867-2383
  • Fax: 505-867-7293
Mailing address:
  • Phone: 505-867-2383
  • Fax: 505-867-7293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number3043
License Number StateNM

VIII. Authorized Official

Name: KIRSTEN MARIE CHOUBARD
Title or Position: EXECUTIVE DIRECTOR
Credential: MSW, LPCC
Phone: 505-867-2383