=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285134080
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DYB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2018
-----------------------------------------------------
Last Update Date | 02/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7100 CARRIAGE RD NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109-2905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-888-4434
-----------------------------------------------------
Fax | 505-293-9899
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7100 CARRIAGE RD NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109-2905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-888-4434
-----------------------------------------------------
Fax | 505-293-9899
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MELISSA Y DOOLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-363-8499
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 5855
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------