Provider Demographics
NPI:1831585413
Name:ENCHANTED LIVING OF NEW MEXICO
Entity type:Organization
Organization Name:ENCHANTED LIVING OF NEW MEXICO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CAREGIVER
Authorized Official - Prefix:MISS
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-771-9098
Mailing Address - Street 1:6217 WILDFLOWER PASS NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-6578
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6217 WILDFLOWER PASS NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-6578
Practice Address - Country:US
Practice Address - Phone:505-771-9098
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1T2271310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility