Provider Demographics
NPI:1295124022
Name:CASA DEL VALLE 1
Entity type:Organization
Organization Name:CASA DEL VALLE 1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SANDOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-877-0275
Mailing Address - Street 1:2111 RAVEN LN SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-4530
Mailing Address - Country:US
Mailing Address - Phone:505-877-0275
Mailing Address - Fax:505-877-1249
Practice Address - Street 1:2111 RAVEN LN SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-4530
Practice Address - Country:US
Practice Address - Phone:505-877-0275
Practice Address - Fax:505-877-1249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-16
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
NM5280310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility