Healthcare Provider Details

I. General information

NPI: 1255164976
Provider Name (Legal Business Name): WILDFLOWER WELLNESS OF NEW MEXICO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 08/20/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1336 WYOMING BLVD NE
ALBUQUERQUE NM
87112-5066
US

IV. Provider business mailing address

1336 WYOMING BLVD NE
ALBUQUERQUE NM
87112-5066
US

V. Phone/Fax

Practice location:
  • Phone: 505-228-7128
  • Fax:
Mailing address:
  • Phone: 505-228-7128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: JOSEFINA BRIANNA ISAACSON
Title or Position: OWNER
Credential: D.O.M.
Phone: 505-228-7128