MEDICARE: DUNGARVIN NEW MEXICO LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1033288626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DUNGARVIN NEW MEXICO LLC

Provider Business Mailing Address
First Line	:	1444 NORTHLAND DR STE 200
Second Line	:
City	:	MENDOTA HEIGHTS
State	:	MN
Zip	:	55120-1032
Country	:	US
Telephone Number	:	651-699-0206
Fax Number	:	651-699-0799

Provider Business Practice Location Address
First Line	:	2309 RENARD PL SE STE 205
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106-4284
Country	:	US
Telephone Number	:	505-998-1060
Fax Number	:	505-998-1066

Authorized Official
Title or Position	:	CEO
Name	:	LORI KRESS
Credential	:
Telephone Number	:	651-699-0206

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	04/27/2023

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