Healthcare Provider Details

I. General information

NPI: 1053947408
Provider Name (Legal Business Name): OPTIMAL WELLNESS JOURNEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 03/30/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 LANG AVE NE STE 110
ALBUQUERQUE NM
87109-4475
US

IV. Provider business mailing address

4801 LANG AVE NE STE 110
ALBUQUERQUE NM
87109-4475
US

V. Phone/Fax

Practice location:
  • Phone: 505-303-3383
  • Fax: 505-672-7924
Mailing address:
  • Phone: 505-303-3383
  • Fax: 505-672-7924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TINA FOLDEN
Title or Position: OWNER
Credential: NP
Phone: 770-605-6491