Provider Demographics
NPI:1235995838
Name:WAKING VALLEY LLC
Entity Type:Organization
Organization Name:WAKING VALLEY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:CUCCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-252-1448
Mailing Address - Street 1:1412 HERTZ DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-5107
Mailing Address - Country:US
Mailing Address - Phone:505-252-1448
Mailing Address - Fax:
Practice Address - Street 1:1412 HERTZ DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5107
Practice Address - Country:US
Practice Address - Phone:505-252-1448
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)