Provider Demographics
NPI:1063677516
Name:LUZ DE VIDA LLC
Entity Type:Organization
Organization Name:LUZ DE VIDA LLC
Other - Org Name:LUZ DE VIDA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PALOMA
Authorized Official - Middle Name:TERESE
Authorized Official - Last Name:BLAIRE
Authorized Official - Suffix:
Authorized Official - Credentials:DO M
Authorized Official - Phone:505-747-7242
Mailing Address - Street 1:PO BOX 2901
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532
Mailing Address - Country:US
Mailing Address - Phone:505-747-7242
Mailing Address - Fax:505-747-7241
Practice Address - Street 1:705 MIDDLE SAN PEDRO
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532
Practice Address - Country:US
Practice Address - Phone:505-747-7242
Practice Address - Fax:505-747-7242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM240171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty