Healthcare Provider Details

I. General information

NPI: 1710805106
Provider Name (Legal Business Name): LA GRAN VIDA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8825 N LOOP DR STE 119
EL PASO TX
79907-4606
US

IV. Provider business mailing address

8825 N LOOP DR STE 119
EL PASO TX
79907-4606
US

V. Phone/Fax

Practice location:
  • Phone: 915-253-9583
  • Fax: 915-301-1304
Mailing address:
  • Phone: 915-253-9583
  • Fax: 915-301-1304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL TED WIRZ
Title or Position: PROGRAM DIRECTOR
Credential: JD
Phone: 915-253-9583