Provider Demographics
NPI:1972500957
Name:LA VIDA LLENA
Entity Type:Organization
Organization Name:LA VIDA LLENA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ANGELES
Authorized Official - Middle Name:
Authorized Official - Last Name:JULIAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:505-291-3100
Mailing Address - Street 1:10701 MONTGOMERY BLVD NE
Mailing Address - Street 2:SUITE F
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3816
Mailing Address - Country:US
Mailing Address - Phone:505-923-4834
Mailing Address - Fax:505-291-3293
Practice Address - Street 1:10501 LAGRIMA DE ORO RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3737
Practice Address - Country:US
Practice Address - Phone:505-296-6700
Practice Address - Fax:505-292-8843
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAVERLAND CARTER LIFESTYLE GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5061314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000I0100Medicaid
NM325035Medicare Oscar/Certification