Provider Demographics
NPI:1538444625
Name:MILAGRO DE VIDA COMMUNITY SERVICES LLC
Entity type:Organization
Organization Name:MILAGRO DE VIDA COMMUNITY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-650-5767
Mailing Address - Street 1:2249 SANTA ANA
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-9082
Mailing Address - Country:US
Mailing Address - Phone:575-650-4444
Mailing Address - Fax:575-523-5504
Practice Address - Street 1:2249 SANTA ANA
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-9082
Practice Address - Country:US
Practice Address - Phone:575-650-4444
Practice Address - Fax:575-523-5504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities