Provider Demographics
NPI:1831354059
Name:LA BUENA VIDA, INC.
Entity type:Organization
Organization Name:LA BUENA VIDA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:MALNAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-867-2383
Mailing Address - Street 1:PO BOX 1147
Mailing Address - Street 2:
Mailing Address - City:BERNALILLO
Mailing Address - State:NM
Mailing Address - Zip Code:87004-1147
Mailing Address - Country:US
Mailing Address - Phone:505-867-2383
Mailing Address - Fax:505-867-2383
Practice Address - Street 1:1005 21ST ST SE
Practice Address - Street 2:SUITES 8 & 10
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4030
Practice Address - Country:US
Practice Address - Phone:505-994-4040
Practice Address - Fax:505-867-2383
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA BUENA VIDA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-28
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3034261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME7034Medicaid