Provider Demographics
NPI:1902123482
Name:MAHARLIKA DYNASTY, LLC
Entity type:Organization
Organization Name:MAHARLIKA DYNASTY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DONOVAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-227-9172
Mailing Address - Street 1:11913 PASEO DORADO CIR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-3785
Mailing Address - Country:US
Mailing Address - Phone:915-227-9172
Mailing Address - Fax:
Practice Address - Street 1:2729 PORTER AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79930-3625
Practice Address - Country:US
Practice Address - Phone:915-566-2111
Practice Address - Fax:915-562-6611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility