Healthcare Provider Details

I. General information

NPI: 1982863999
Provider Name (Legal Business Name): BUENA VIDA PHYSICAL THERAPY AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2008
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E LINCOLN ST
LAS VEGAS NM
87701-4502
US

IV. Provider business mailing address

601 E LINCOLN ST
LAS VEGAS NM
87701-4502
US

V. Phone/Fax

Practice location:
  • Phone: 505-425-2998
  • Fax: 505-425-2897
Mailing address:
  • Phone: 505-425-2998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number3283
License Number StateNM

VIII. Authorized Official

Name: MS. STELLA JEANNE BURCIAGA
Title or Position: PRESIDENT
Credential: PT
Phone: 505-718-8309