Healthcare Provider Details

I. General information

NPI: 1306232038
Provider Name (Legal Business Name): ENCHANTMENT LEGACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 04/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 WILLIAMS AVE
ESTANCIA NM
87016-0697
US

IV. Provider business mailing address

PO BOX 697
ESTANCIA NM
87016-0697
US

V. Phone/Fax

Practice location:
  • Phone: 505-384-3032
  • Fax: 505-384-3033
Mailing address:
  • Phone: 505-384-3032
  • Fax: 505-384-3033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number172V00000X
License Number StateNM

VIII. Authorized Official

Name: MRS. THERESA L. MUTH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 505-384-3032