Provider Demographics
NPI:1578728705
Name:LA BUENA VIDA, INC.
Entity Type:Organization
Organization Name:LA BUENA VIDA, INC.
Other - Org Name:LA BUENA VIDA, INC. - LOS LUNAS OFFICE
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CHOUBARD
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:505-867-2383
Mailing Address - Street 1:303 LUNA ST SE
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-9277
Mailing Address - Country:US
Mailing Address - Phone:505-565-1619
Mailing Address - Fax:505-565-1620
Practice Address - Street 1:303 LUNA ST SE
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-9277
Practice Address - Country:US
Practice Address - Phone:505-565-1619
Practice Address - Fax:505-565-1620
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA BUENA VIDA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-28
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