=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023373370
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARIPOSA SENIOR CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2012
-----------------------------------------------------
Last Update Date | 07/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3811 ACADEMY PKWY S NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-234-1744
-----------------------------------------------------
Fax | 505-234-1733
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3811 ACADEMY PKWY S NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-234-1744
-----------------------------------------------------
Fax | 505-234-1733
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JASON MCDERMOTT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-234-1744
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 1T3404
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------