Healthcare Provider Details

I. General information

NPI: 1467549659
Provider Name (Legal Business Name): THI OF NEW MEXICO AT VIDA ENCANTADA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2006
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 COLLINS DR
LAS VEGAS NM
87701-4826
US

IV. Provider business mailing address

930 RIDGEBROOK RD
SPARKS MD
21152-9390
US

V. Phone/Fax

Practice location:
  • Phone: 505-425-9362
  • Fax: 505-425-3152
Mailing address:
  • Phone: 410-773-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: SHARON INOUE
Title or Position: PRESIDENT
Credential:
Phone: 505-425-9362