Healthcare Provider Details

I. General information

NPI: 1467760892
Provider Name (Legal Business Name): DIAMOND CARE VIDA ENCANTADA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2010
Last Update Date: 03/16/2015
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

2301 COLLINS DR
LAS VEGAS NM
87701-4826
US

V. Phone/Fax

Practice location:
  • Phone: 505-425-9362
  • Fax: 505-425-8518
Mailing address:
  • Phone: 505-425-9362
  • Fax: 505-425-8518

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: MR. HARVEY PELOVSKY
Title or Position: MANAGING PARTNER
Credential:
Phone: 928-978-0520