Healthcare Provider Details

I. General information

NPI: 1285053918
Provider Name (Legal Business Name): INTEGRATED WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3615 HIGHWAY 528 NW STE 106
ALBUQUERQUE NM
87114-8919
US

IV. Provider business mailing address

3615 HIGHWAY 528 NW STE 106
ALBUQUERQUE NM
87114-8919
US

V. Phone/Fax

Practice location:
  • Phone: 505-899-4334
  • Fax: 505-792-4236
Mailing address:
  • Phone: 505-899-4334
  • Fax: 505-792-4236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-0959
License Number StateNM

VIII. Authorized Official

Name: MRS. TIFFANY HAYS
Title or Position: PATIENT SERVICES COORDINATOR
Credential:
Phone: 505-899-4334