Healthcare Provider Details

I. General information

NPI: 1750448056
Provider Name (Legal Business Name): LA VIDA FELICIDAD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 SUN RANCH VILLAGE LOOP SW
LOS LUNAS NM
87031-4809
US

IV. Provider business mailing address

PO BOX 2040
LOS LUNAS NM
87031-2040
US

V. Phone/Fax

Practice location:
  • Phone: 505-565-1614
  • Fax: 505-565-1608
Mailing address:
  • Phone: 505-565-1614
  • Fax: 505-565-1608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number5604
License Number StateNM

VIII. Authorized Official

Name: MR. MARTIN ISAIAS MONDRAGON
Title or Position: ASSOCIATE DIRECTOR
Credential:
Phone: 505-565-1614