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General NPI Number Information
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NPI Number | 1033519897
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Entity Type | Organization
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Legal Business Name | LOYAL SERVICE AGENCY INC.
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Dates
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Enumeration Date | 08/29/2014
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Last Update Date | 08/29/2014
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Provider Practice Location Address
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Address Line | 103 GOLTZ DR
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City | GRANTS
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State | NM
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Zip | 87020-2155
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Country | US
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Telephone | 505-285-2966
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Fax | 505-285-4055
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Provider Business Mailing Address
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Address Line | 103 GOLTZ DR
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City | GRANTS
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State | NM
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Zip | 87020-2155
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Country | US
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Telephone | 505-285-2966
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Fax | 505-285-4055
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Authorized Official
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Title or Position | OWNER
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Name | MRS. LONNEL M SANDOVAL-ASEBEDO
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Credential | R.N.
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Telephone | 505-285-2966
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 3351
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License Number State | NM
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