Provider Demographics
NPI:1326230483
Name:CANYON TRANSITIONAL REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:CANYON TRANSITIONAL REHABILITATION CENTER, LLC
Other - Org Name:CANYON TRANSITIONAL REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4752
Mailing Address - Street 1:10101 LAGRIMA DE ORO RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-6022
Mailing Address - Country:US
Mailing Address - Phone:505-298-1231
Mailing Address - Fax:505-298-2098
Practice Address - Street 1:10101 LAGRIMA DE ORO RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-6022
Practice Address - Country:US
Practice Address - Phone:505-298-1231
Practice Address - Fax:505-298-2098
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-13
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1070314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM325054Medicare Oscar/Certification