Provider Demographics
NPI:1164937199
Name:ENCHANTED HILLS HOME HEALTHCARE AGENCY, INC.
Entity Type:Organization
Organization Name:ENCHANTED HILLS HOME HEALTHCARE AGENCY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:505-867-0621
Mailing Address - Street 1:7555 ENCHANTED HILLS BLVD NE STE 200
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-8625
Mailing Address - Country:US
Mailing Address - Phone:505-867-0621
Mailing Address - Fax:
Practice Address - Street 1:4273 MONTGOMERY BLVD. NE
Practice Address - Street 2:BUILDING K STE. 130
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-867-0621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ENCHANTED HILLS HOME HEALTH CARE AGENCY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3202B1251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM75208067Medicaid
NM94935505Medicaid