Healthcare Provider Details

I. General information

NPI: 1104442847
Provider Name (Legal Business Name): BELLA VIDA HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2020
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 N ALAMEDA BLVD
LAS CRUCES NM
88005-2128
US

IV. Provider business mailing address

PO BOX 1731
LAS CRUCES NM
88004-1731
US

V. Phone/Fax

Practice location:
  • Phone: 575-288-1336
  • Fax: 575-222-4453
Mailing address:
  • Phone: 575-288-1336
  • Fax: 575-222-4453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. DIANA MARIE PORTILLO
Title or Position: OWNER/PROVIDER
Credential: DNP
Phone: 575-288-1336