Provider Demographics
NPI:1033519897
Name:LOYAL SERVICE AGENCY INC.
Entity Type:Organization
Organization Name:LOYAL SERVICE AGENCY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LONNEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:SANDOVAL-ASEBEDO
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:505-285-2966
Mailing Address - Street 1:103 GOLTZ DR
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-2155
Mailing Address - Country:US
Mailing Address - Phone:505-285-2966
Mailing Address - Fax:505-285-4055
Practice Address - Street 1:103 GOLTZ DR
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2155
Practice Address - Country:US
Practice Address - Phone:505-285-2966
Practice Address - Fax:505-285-4055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3351251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health