Provider Demographics
NPI:1578672424
Name:ENCHANTED HILLS HOME HEALTHCARE AGENCY, INC.
Entity Type:Organization
Organization Name:ENCHANTED HILLS HOME HEALTHCARE AGENCY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:KELLENE
Authorized Official - Last Name:JOHNS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:505-867-0621
Mailing Address - Street 1:7555 ENCHANTED HILLS BLVD NE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-8625
Mailing Address - Country:US
Mailing Address - Phone:505-867-0621
Mailing Address - Fax:505-867-0623
Practice Address - Street 1:7555 ENCHANTED HILLS BLVD.
Practice Address - Street 2:SUITE 200
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-8525
Practice Address - Country:US
Practice Address - Phone:505-867-0621
Practice Address - Fax:505-867-0623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3202251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM75208067Medicaid
NM94935505Medicaid