Provider Demographics
NPI:1376988576
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:SHIRLEY
Authorized Official - Middle Name:CHILTON
Authorized Official - Last Name:MALDONADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-384-3032
Mailing Address - Street 1:PO BOX 697
Mailing Address - Street 2:514 W WILLIAMS
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 W. 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:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM46533753172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty