Provider Demographics
NPI:1508020975
Name:SENIOR CITIZEN RESIDENT CENTER
Entity Type:Organization
Organization Name:SENIOR CITIZEN RESIDENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:SHONKWILER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-762-8052
Mailing Address - Street 1:2210 MARBY DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-8306
Mailing Address - Country:US
Mailing Address - Phone:575-762-8052
Mailing Address - Fax:575-769-1553
Practice Address - Street 1:2210 MARBY DRIVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-8306
Practice Address - Country:US
Practice Address - Phone:575-762-8052
Practice Address - Fax:575-769-1553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-15
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5539310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility