Basic Information
| Provider Information | |||||||||
| NPI: | 1134167679 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALOMA BLANCA HEALTH CARE ASSOCIATES, LLC | ||||||||
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| OtherOrganizationName: | PALOMA BLANCA HEALTH AND REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1509 UNIVERSITY BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871021708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052432257 | ||||||||
| FaxNumber: | 5052471784 | ||||||||
| Practice Location | |||||||||
| Address1: | 1509 UNIVERSITY BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871021708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052432257 | ||||||||
| FaxNumber: | 5052471784 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 06/09/2016 | ||||||||
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| AuthorizedOfficialLastName: | PANNELL | ||||||||
| AuthorizedOfficialFirstName: | CATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5052432257 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1076 | NM | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 021218915 | 05 | NM | MEDICAID | 96323795 | 05 | NM | MEDICAID | 7103233 | 05 | NM | MEDICAID |