Healthcare Provider Details

I. General information

NPI: 1093497851
Provider Name (Legal Business Name): LIFECARE MOUNTAIN HOSPICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 WASHINGTON AVENUE SUITE 215
SANTE FE NM
87501
US

IV. Provider business mailing address

PO BOX 733707
DALLAS TX
75373-3707
US

V. Phone/Fax

Practice location:
  • Phone: 505-633-6683
  • Fax: 505-633-6684
Mailing address:
  • Phone: 806-451-5090
  • Fax: 469-331-0387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State

VIII. Authorized Official

Name: TONYA COWLING
Title or Position: DIRECTOR OF REVENUE
Credential:
Phone: 806-451-5090