Provider Demographics
NPI:1184949422
Name:LUNA DE COBRE THERAPY CENTER, LLC
Entity type:Organization
Organization Name:LUNA DE COBRE THERAPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:MARGARITA
Authorized Official - Middle Name:
Authorized Official - Last Name:SILVA POTTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-590-2202
Mailing Address - Street 1:PO BOX 1003
Mailing Address - Street 2:
Mailing Address - City:BAYARD
Mailing Address - State:NM
Mailing Address - Zip Code:88023-1003
Mailing Address - Country:US
Mailing Address - Phone:575-590-2202
Mailing Address - Fax:
Practice Address - Street 1:807 GRANT ST.
Practice Address - Street 2:
Practice Address - City:BAYARD
Practice Address - State:NM
Practice Address - Zip Code:88023
Practice Address - Country:US
Practice Address - Phone:575-590-2202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0101621101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty