Healthcare Provider Details

I. General information

NPI: 1144013103
Provider Name (Legal Business Name): LIFEHOUSE VISTA TAOS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2025
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 BLUEBERRY HILL RD
EL PRADO NM
87529-7305
US

IV. Provider business mailing address

PO BOX 3141
CARLSBAD NM
88221-3141
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-5858
  • Fax:
Mailing address:
  • Phone: 575-302-8304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY SUSAN ROGGE-ROGERS
Title or Position: EXECUTIVE ADMINISTRATOR
Credential:
Phone: 575-302-8304