=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124470703
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE FAMILY HEALTHCARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2016
-----------------------------------------------------
Last Update Date | 07/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 717 ENCINO PL NE SUITE 4
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87102-2611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 150-537-9394
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 717 ENCINO PL NE SUITE 4
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87102-2611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CNP
-----------------------------------------------------
Name | MARILOU T LINATOC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-379-3941
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | CNP 01894
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------