Healthcare Provider Details

I. General information

NPI: 1033519897
Provider Name (Legal Business Name): LOYAL SERVICE AGENCY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2014
Last Update Date: 08/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 GOLTZ DR
GRANTS NM
87020-2155
US

IV. Provider business mailing address

103 GOLTZ DR
GRANTS NM
87020-2155
US

V. Phone/Fax

Practice location:
  • Phone: 505-285-2966
  • Fax: 505-285-4055
Mailing address:
  • Phone: 505-285-2966
  • Fax: 505-285-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number3351
License Number StateNM

VIII. Authorized Official

Name: MRS. LONNEL M SANDOVAL-ASEBEDO
Title or Position: OWNER
Credential: R.N.
Phone: 505-285-2966