Provider Demographics
NPI:1760699334
Name:THI OF NEW MEXICO AT EN SU CASA LLC
Entity Type:Organization
Organization Name:THI OF NEW MEXICO AT EN SU CASA LLC
Other - Org Name:EN SU CASA PERSONAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PEBSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-522-7000
Mailing Address - Street 1:930 RIDGEBROOK RD
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9390
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8820 HORIZON BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-1689
Practice Address - Country:US
Practice Address - Phone:505-823-1885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM24273881Medicaid