Provider Demographics
NPI:1093280281
Name:DIAMOND CARE SANTA FE LLC
Entity Type:Organization
Organization Name:DIAMOND CARE SANTA FE LLC
Other - Org Name:DIAMOND CARE SANTA FE CARE CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-652-5628
Mailing Address - Street 1:807 W. LONGHORN RD.
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541
Mailing Address - Country:US
Mailing Address - Phone:928-978-0520
Mailing Address - Fax:928-474-0505
Practice Address - Street 1:635 HARKLE ROAD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-982-2574
Practice Address - Fax:505-988-1942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-04
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM22757279Medicaid