Provider Demographics
NPI:1720243173
Name:HOUSE OF HEARTS
Entity Type:Organization
Organization Name:HOUSE OF HEARTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:KEENAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-977-2074
Mailing Address - Street 1:2612 CHELWOOD PARK BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-1978
Mailing Address - Country:US
Mailing Address - Phone:505-506-7901
Mailing Address - Fax:505-294-1278
Practice Address - Street 1:2612 CHELWOOD PARK BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-1978
Practice Address - Country:US
Practice Address - Phone:505-506-7901
Practice Address - Fax:505-294-1278
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOUSE OF HEARTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMFA0080936163WG0000X, 320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty