=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619390333
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REHAB SUITES AT LAS ESTANCIAS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2014
-----------------------------------------------------
Last Update Date | 10/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3620 LAS ESTANCIAS DRIVE SW
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-253-9600
-----------------------------------------------------
Fax | 505-944-7091
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8820 HORIZON BLVD NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87113-1689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-998-6254
-----------------------------------------------------
Fax | 505-944-7091
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | DENNIS WARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 318-267-6515
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------