Healthcare Provider Details

I. General information

NPI: 1457105835
Provider Name (Legal Business Name): UNLIMITED POTENTIAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2024
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4146 CALLE DE LUNA
LAS CRUCES NM
88012-7635
US

IV. Provider business mailing address

4146 CALLE DE LUNA
LAS CRUCES NM
88012-7635
US

V. Phone/Fax

Practice location:
  • Phone: 575-621-2573
  • Fax:
Mailing address:
  • Phone: 575-621-2573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RUTH ROMAN
Title or Position: OWNER, CEO
Credential:
Phone: 575-621-2573