Healthcare Provider Details

I. General information

NPI: 1992043780
Provider Name (Legal Business Name): ADVANTAGE PERSONAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2013
Last Update Date: 01/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

588 CANAL BLVD SW
LOS LUNAS NM
87031-8603
US

IV. Provider business mailing address

588 CANAL BLVD SW
LOS LUNAS NM
87031
US

V. Phone/Fax

Practice location:
  • Phone: 505-681-1200
  • Fax:
Mailing address:
  • Phone: 505-681-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number03260555002
License Number StateNM

VIII. Authorized Official

Name: ABBAS MICHAEL KHAVARI
Title or Position: OWNER
Credential:
Phone: 505-681-1200