Provider Demographics
NPI:1003128349
Name:BUENA SUERTE, INC.
Entity Type:Organization
Organization Name:BUENA SUERTE, INC.
Other - Org Name:COMFORT KEEPERS #697
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:L
Authorized Official - Last Name:GAMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-639-3822
Mailing Address - Street 1:387 LAKE HAVASU AVE S
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-9306
Mailing Address - Country:US
Mailing Address - Phone:928-855-0005
Mailing Address - Fax:928-855-0075
Practice Address - Street 1:387 LAKE HAVASU AVE S
Practice Address - Street 2:SUITE 102
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-9306
Practice Address - Country:US
Practice Address - Phone:928-855-0005
Practice Address - Fax:928-855-0075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-01
Last Update Date:2011-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ253Z00000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ531351Medicaid