Healthcare Provider Details

I. General information

NPI: 1881900579
Provider Name (Legal Business Name): WESLEY & EDWIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2010
Last Update Date: 08/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 CONCHAS ST NE
ALBUQUERQUE NM
87123-2703
US

IV. Provider business mailing address

7905 MARQUETTE AVE NE UNIT B
ALBUQUERQUE NM
87108-6703
US

V. Phone/Fax

Practice location:
  • Phone: 505-550-2642
  • Fax: 267-276-0511
Mailing address:
  • Phone: 505-550-2642
  • Fax: 267-276-0511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: TRACEE M ASHLEY-HOLDEN
Title or Position: DIRECTOR
Credential:
Phone: 505-550-2642