Healthcare Provider Details

I. General information

NPI: 1205784147
Provider Name (Legal Business Name): WINTER LILY POOL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2026
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7609 WELLS FARGO TRL NW
ALBUQUERQUE NM
87120-2848
US

IV. Provider business mailing address

10511 GOLF COURSE RD NW STE 103
ALBUQUERQUE NM
87114-5917
US

V. Phone/Fax

Practice location:
  • Phone: 505-803-9364
  • Fax: 505-803-9364
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: