Provider Demographics
NPI:1306232038
Name:ENCHANTMENT LEGACY, INC.
Entity Type:Organization
Organization Name:ENCHANTMENT LEGACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-384-3032
Mailing Address - Street 1:PO BOX 697
Mailing Address - Street 2:
Mailing Address - City:ESTANCIA
Mailing Address - State:NM
Mailing Address - Zip Code:87016-0697
Mailing Address - Country:US
Mailing Address - Phone:505-384-3032
Mailing Address - Fax:505-384-3033
Practice Address - Street 1:514 WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:ESTANCIA
Practice Address - State:NM
Practice Address - Zip Code:87016-0697
Practice Address - Country:US
Practice Address - Phone:505-384-3032
Practice Address - Fax:505-384-3033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM172V00000X253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care