Provider Demographics
NPI:1144519182
Name:ENCHANTED HEALING OF NEW MEXICO, LLC
Entity type:Organization
Organization Name:ENCHANTED HEALING OF NEW MEXICO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DELASARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIHON
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:505-362-5847
Mailing Address - Street 1:21 KUHN DR
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059-8101
Mailing Address - Country:US
Mailing Address - Phone:505-362-5847
Mailing Address - Fax:201-530-8616
Practice Address - Street 1:122 BRYN MAWR DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2210
Practice Address - Country:US
Practice Address - Phone:505-362-5847
Practice Address - Fax:201-530-8616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-30
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-06142251B00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM55088279Medicaid