Provider Demographics
NPI:1982372223
Name:GREAT LIVIN II LLC
Entity Type:Organization
Organization Name:GREAT LIVIN II LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:J
Authorized Official - Last Name:POEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-246-6971
Mailing Address - Street 1:2400 MONROE ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-4063
Mailing Address - Country:US
Mailing Address - Phone:505-246-6971
Mailing Address - Fax:
Practice Address - Street 1:617 MADEIRA DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1417
Practice Address - Country:US
Practice Address - Phone:505-246-6971
Practice Address - Fax:505-247-2191
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT LIVIN II LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-09-01
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM49852591Medicaid