Healthcare Provider Details

I. General information

NPI: 1699102467
Provider Name (Legal Business Name): ENHANCED WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2013
Last Update Date: 10/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 EUBANK BLVD NE SUITE C3
ALBUQUERQUE NM
87111
US

IV. Provider business mailing address

5200 EUBANK BLVD NE SUITE C3
ALBUQUERQUE NM
87111
US

V. Phone/Fax

Practice location:
  • Phone: 505-323-8100
  • Fax: 505-292-0555
Mailing address:
  • Phone: 505-323-8100
  • Fax: 505-292-0555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number637RX2
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number90-216
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number90-216
License Number StateNM

VIII. Authorized Official

Name: JAN C. JAY
Title or Position: OWNER
Credential: DOM
Phone: 505-323-8100