Provider Demographics
NPI:1568866085
Name:RE-CYCLED MAN LLC
Entity Type:Organization
Organization Name:RE-CYCLED MAN LLC
Other - Org Name:A NEW AWAKENING RIO RANCHO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERICK
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:PACHECO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-489-4935
Mailing Address - Street 1:412 ASBURY RD NE
Mailing Address - Street 2:SUITE C
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-5627
Mailing Address - Country:US
Mailing Address - Phone:505-489-4935
Mailing Address - Fax:
Practice Address - Street 1:1207 GOLF COURSE RD SE
Practice Address - Street 2:SUITE C
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1999
Practice Address - Country:US
Practice Address - Phone:505-994-4100
Practice Address - Fax:505-994-1229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-13
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM93588755Medicaid
NM32D2113373OtherCLINICAL LABORATORY IMPROVMENT AMENDMENTS CERTIFICATE OF WAIVER
NM93588755Medicaid