Provider Demographics
NPI:1386676856
Name:LA BUENA VIDA, INC.
Entity Type:Organization
Organization Name:LA BUENA VIDA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CHOUBARD
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LPCC
Authorized Official - Phone:505-867-2383
Mailing Address - Street 1:PO BOX 1147
Mailing Address - Street 2:
Mailing Address - City:BERNALILLO
Mailing Address - State:NM
Mailing Address - Zip Code:87004-1147
Mailing Address - Country:US
Mailing Address - Phone:505-867-2383
Mailing Address - Fax:505-867-7293
Practice Address - Street 1:872 CAMINO DEL PUEBLO
Practice Address - Street 2:
Practice Address - City:BERNALILLO
Practice Address - State:NM
Practice Address - Zip Code:87004
Practice Address - Country:US
Practice Address - Phone:505-867-2383
Practice Address - Fax:505-867-7293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3043261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME7034Medicaid