Healthcare Provider Details

I. General information

NPI: 1558668434
Provider Name (Legal Business Name): CIRCLE OF LIFE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2011
Last Update Date: 04/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102A PASEO DE ONATE
ESPANOLA NM
87532
US

IV. Provider business mailing address

PO BOX 969
SAN JUAN PUEBLO NM
87566-0969
US

V. Phone/Fax

Practice location:
  • Phone: 505-852-1377
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberM-07620
License Number StateNM

VIII. Authorized Official

Name: SUE CHAVEZ
Title or Position: BILLING SPECIALIST
Credential:
Phone: 505-852-1977