Healthcare Provider Details

I. General information

NPI: 1639572159
Provider Name (Legal Business Name): LISA ABEYTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2014
Last Update Date: 01/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 12TH AVE SW
RIO RANCHO NM
87124
US

IV. Provider business mailing address

809 12TH AVE SW
RIO RANCHO NM
87124-0748
US

V. Phone/Fax

Practice location:
  • Phone: 505-977-0979
  • Fax: 505-896-6922
Mailing address:
  • Phone: 505-977-0979
  • Fax: 505-896-6922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number14-00005321
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: