Healthcare Provider Details

I. General information

NPI: 1124800776
Provider Name (Legal Business Name): BLOOM HAVEN BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

741 TIWA LN NE
RIO RANCHO NM
87124-1510
US

IV. Provider business mailing address

1380 RIO RANCHO BLVD SE # 431
RIO RANCHO NM
87124-1006
US

V. Phone/Fax

Practice location:
  • Phone: 505-900-4029
  • Fax: 505-317-7133
Mailing address:
  • Phone: 505-900-4029
  • Fax: 505-317-7133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LISA LUJAN
Title or Position: CEO
Credential:
Phone: 505-916-4729