Healthcare Provider Details

I. General information

NPI: 1831585413
Provider Name (Legal Business Name): ENCHANTED LIVING OF NEW MEXICO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2015
Last Update Date: 04/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6217 WILDFLOWER PASS NE
RIO RANCHO NM
87144-6578
US

IV. Provider business mailing address

6217 WILDFLOWER PASS NE
RIO RANCHO NM
87144-6578
US

V. Phone/Fax

Practice location:
  • Phone: 505-771-9098
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number1T2271
License Number StateNM

VIII. Authorized Official

Name: MISS DANIELLE DACOSTA
Title or Position: ADMINISTRATOR/CAREGIVER
Credential:
Phone: 505-771-9098