Healthcare Provider Details

I. General information

NPI: 1316638232
Provider Name (Legal Business Name): CIELITO LINDO WAIVER SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2023
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2327 CALLE REINA
SANTA FE NM
87507-6909
US

IV. Provider business mailing address

2327 CALLE REINA
SANTA FE NM
87507-6909
US

V. Phone/Fax

Practice location:
  • Phone: 505-920-6031
  • Fax:
Mailing address:
  • Phone: 505-920-6031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name: PEDRO GONZALEZ
Title or Position: DIRECTOR
Credential: MBA
Phone: 505-920-6031