Basic Information
| Provider Information | |||||||||
| NPI: | 1316926041 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAGUNA RAINBOW CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAGUNA RAINBOW NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 490 | ||||||||
| Address2: | |||||||||
| City: | CASA BLANCA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870070490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055526034 | ||||||||
| FaxNumber: | 5055527645 | ||||||||
| Practice Location | |||||||||
| Address1: | I-40, EXIT 108 | ||||||||
| Address2: | 1/2 MILE SOUTH STATE ROAD 23 | ||||||||
| City: | CASA BLANCA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870070490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055526034 | ||||||||
| FaxNumber: | 5055527645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2006 | ||||||||
| LastUpdateDate: | 03/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | KORETKE | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 3039873088 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 5063 | NM | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | I0365 | 05 | NM | MEDICAID |