Provider Demographics
NPI:1720634165
Name:LUNA VISTA HOSPICE LLC
Entity Type:Organization
Organization Name:LUNA VISTA HOSPICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR /OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-977-3131
Mailing Address - Street 1:2116 VISTA OESTE NW
Mailing Address - Street 2:# 1B
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-4340
Mailing Address - Country:US
Mailing Address - Phone:505-977-1165
Mailing Address - Fax:505-247-6811
Practice Address - Street 1:2116 VISTA OESTE NW
Practice Address - Street 2:# 1B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-4340
Practice Address - Country:US
Practice Address - Phone:505-977-1165
Practice Address - Fax:505-247-6811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-12
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based