MEDICARE: GREAT LIVIN II 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	315P00000X	Intellectual Disabilities Intermediate Care Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750947420
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LIVIN II LLC

Provider Business Mailing Address
First Line	:	2400 MONROE ST NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-4063
Country	:	US
Telephone Number	:	505-246-6971
Fax Number	:	505-247-2191

Provider Business Practice Location Address
First Line	:	4028 MESCALERO RD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-1754
Country	:	US
Telephone Number	:	505-246-6971
Fax Number	:	505-247-2191

Authorized Official
Title or Position	:	OWNER
Name	:	MATT POEL
Credential	:
Telephone Number	:	505-246-6971

Provider Enumeration Date	:	05/17/2019
Last Update Date	:	05/13/2024

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Directions to “GREAT LIVIN II LLC ” Practice Location

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