Provider Demographics
NPI:1316926041
Name:LAGUNA RAINBOW CORPORATION
Entity type:Organization
Organization Name:LAGUNA RAINBOW CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KORETKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-987-3088
Mailing Address - Street 1:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:CASA BLANCA
Mailing Address - State:NM
Mailing Address - Zip Code:87007-0490
Mailing Address - Country:US
Mailing Address - Phone:505-552-6034
Mailing Address - Fax:505-552-7645
Practice Address - Street 1:I-40, EXIT 108
Practice Address - Street 2:1/2 MILE SOUTH STATE ROAD 23
Practice Address - City:CASA BLANCA
Practice Address - State:NM
Practice Address - Zip Code:87007-0490
Practice Address - Country:US
Practice Address - Phone:505-552-6034
Practice Address - Fax:505-552-7645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5063314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMI0365Medicaid