Healthcare Provider Details

I. General information

NPI: 1831354059
Provider Name (Legal Business Name): LA BUENA VIDA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2008
Last Update Date: 09/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 21ST ST SE SUITES 8 & 10
RIO RANCHO NM
87124-4030
US

IV. Provider business mailing address

PO BOX 1147
BERNALILLO NM
87004-1147
US

V. Phone/Fax

Practice location:
  • Phone: 505-994-4040
  • Fax: 505-867-2383
Mailing address:
  • Phone: 505-867-2383
  • Fax: 505-867-2383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number3034
License Number StateNM

VIII. Authorized Official

Name: MR. STEVE MALNAR
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 505-867-2383