Provider Demographics
NPI:1194772939
Name:PEAK MEDICAL ASSISTED LIVING, LLC
Entity type:Organization
Organization Name:PEAK MEDICAL ASSISTED LIVING, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4752
Mailing Address - Street 1:2884 N ROADRUNNER PKWY
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-0853
Mailing Address - Country:US
Mailing Address - Phone:575-522-1110
Mailing Address - Fax:
Practice Address - Street 1:2884 N ROADRUNNER PKWY
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-0853
Practice Address - Country:US
Practice Address - Phone:575-522-1110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEAK MEDICAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5788310400000X
NM5789311500000X
NM5841314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPROVA41670OtherMOLINA
NMM156OtherBC/BS OF NM
NMM156OtherBC/BS OF NM