Healthcare Provider Details

I. General information

NPI: 1043713415
Provider Name (Legal Business Name): SOUTHWEST RECOVERY AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 03/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3874 MASTHEAD ST NE
ALBUQUERQUE NM
87109-4479
US

IV. Provider business mailing address

914 PINEHURST RD SE
RIO RANCHO NM
87124-2219
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-9412
  • Fax: 505-895-2505
Mailing address:
  • Phone: 323-854-8587
  • Fax: 505-896-2505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT D. MILLER
Title or Position: PRESIDENT
Credential:
Phone: 323-854-8587