Healthcare Provider Details

I. General information

NPI: 1669869988
Provider Name (Legal Business Name): HIGHLAND CONSTRUCTION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 8TH ST
LAS VEGAS NM
87701-4251
US

IV. Provider business mailing address

614 8TH ST
LAS VEGAS NM
87701-4251
US

V. Phone/Fax

Practice location:
  • Phone: 505-425-3644
  • Fax: 505-454-0787
Mailing address:
  • Phone: 505-425-3644
  • Fax: 505-454-0787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number384112
License Number StateNM

VIII. Authorized Official

Name: MR. MICHAEL QUINTANA
Title or Position: SOLE OWNER
Credential:
Phone: 505-425-3644