MEDICARE: ENCHANTED LIVING OF NEW MEXICO

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	310400000X	Assisted Living Facility	1T2271	NM

General Provider Information

NPI Number	:	1831585413
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENCHANTED LIVING OF NEW MEXICO

Provider Business Mailing Address
First Line	:	6217 WILDFLOWER PASS NE
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87144-6578
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6217 WILDFLOWER PASS NE
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87144-6578
Country	:	US
Telephone Number	:	505-771-9098
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR/CAREGIVER
Name	:	MISS DANIELLE DACOSTA
Credential	:
Telephone Number	:	505-771-9098

Provider Enumeration Date	:	04/10/2015
Last Update Date	:	04/10/2015

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