=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881750677
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEAVITT ENTERPRISES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4005 CLINTON BLVD SW
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87105-6122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-877-3627
-----------------------------------------------------
Fax | 505-877-0627
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4005 CLINTON BLVD SW
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87105-6122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-877-3627
-----------------------------------------------------
Fax | 505-877-0627
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. PATSY E LEAVITT
-----------------------------------------------------
Credential | RN RETIRED
-----------------------------------------------------
Telephone | 505-877-3627
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number | 03019401006
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------