Provider Demographics
NPI:1467760892
Name:DIAMOND CARE VIDA ENCANTADA, LLC
Entity Type:Organization
Organization Name:DIAMOND CARE VIDA ENCANTADA, LLC
Other - Org Name:VIDAN ENCANTADA NURSING AND REHAB CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HARVEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PELOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-978-0520
Mailing Address - Street 1:2301 COLLINS DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4826
Mailing Address - Country:US
Mailing Address - Phone:505-425-9362
Mailing Address - Fax:505-425-8518
Practice Address - Street 1:2301 COLLINS DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4826
Practice Address - Country:US
Practice Address - Phone:505-425-9362
Practice Address - Fax:505-425-8518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-20
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM325065Medicare Oscar/Certification