Basic Information
Provider Information | |||||||||
NPI: | 1285921569 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TRANSITIONAL LIVING SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5601 DOMINGO RD NE | ||||||||
Address2: |   | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871081610 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5052685295 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5601 DOMINGO RD NE | ||||||||
Address2: |   | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871081610 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5052685295 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2011 | ||||||||
LastUpdateDate: | 07/07/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JACKSON | ||||||||
AuthorizedOfficialFirstName: | GARY | ||||||||
AuthorizedOfficialMiddleName: | B | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5052685295 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 105341 | NM | Y |   | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |   |
ID Information
ID | Type | State | Issuer | Description | B9311 | 05 | NM |   | MEDICAID |