Provider Demographics
NPI:1982863999
Name:BUENA VIDA PHYSICAL THERAPY AND WELLNESS LLC
Entity Type:Organization
Organization Name:BUENA VIDA PHYSICAL THERAPY AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:JEANNE
Authorized Official - Last Name:BURCIAGA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:505-718-8309
Mailing Address - Street 1:601 E LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4502
Mailing Address - Country:US
Mailing Address - Phone:505-425-2998
Mailing Address - Fax:
Practice Address - Street 1:601 E LINCOLN ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4502
Practice Address - Country:US
Practice Address - Phone:505-425-2998
Practice Address - Fax:505-425-2897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3283261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM36072842Medicaid
NM36072842Medicaid