Healthcare Provider Details

I. General information

NPI: 1164180725
Provider Name (Legal Business Name): BLUE HORIZON HOME CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 12/01/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

06 LAMBDA ST SP 1
MENTMORE NM
87319-8731
US

IV. Provider business mailing address

PO BOX 3325
GALLUP NM
87305-3325
US

V. Phone/Fax

Practice location:
  • Phone: 480-710-8411
  • Fax:
Mailing address:
  • Phone: 480-710-8411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name: SHINASHA BENALLY
Title or Position: CEO/OWNER
Credential:
Phone: 480-710-8411