Provider Demographics
NPI:1639572159
Name:ABEYTA, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ABEYTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 12TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-0748
Mailing Address - Country:US
Mailing Address - Phone:505-977-0979
Mailing Address - Fax:505-896-6922
Practice Address - Street 1:809 12TH AVE SW
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124
Practice Address - Country:US
Practice Address - Phone:505-977-0979
Practice Address - Fax:505-896-6922
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM14-00005321320700000X
310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities