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General NPI Number Information
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NPI Number | 1386676856
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Entity Type | Organization
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Legal Business Name | LA BUENA VIDA, INC.
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Dates
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Enumeration Date | 07/07/2006
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Last Update Date | 07/28/2008
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Provider Practice Location Address
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Address Line | 872 CAMINO DEL PUEBLO
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City | BERNALILLO
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State | NM
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Zip | 87004
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Country | US
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Telephone | 505-867-2383
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Fax | 505-867-7293
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Provider Business Mailing Address
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Address Line | PO BOX 1147
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City | BERNALILLO
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State | NM
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Zip | 87004-1147
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Country | US
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Telephone | 505-867-2383
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Fax | 505-867-7293
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | KIRSTEN MARIE CHOUBARD
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Credential | MSW, LPCC
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Telephone | 505-867-2383
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 3043
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License Number State | NM
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