=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932591237
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MESA ARRIBA FAMILY CARE HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2015
-----------------------------------------------------
Last Update Date | 02/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7620 BUCKBOARD AVE NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109-5102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-239-5101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7620 BUCKBOARD AVE NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109-5102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-239-5101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATOR
-----------------------------------------------------
Name | MRS. SENA M SWINNEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-239-5101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 5703
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------