Healthcare Provider Details

I. General information

NPI: 1902480692
Provider Name (Legal Business Name): BLUE SPHERE WELLNESS LLC DBA BIENESTAR ESPHERA AZUL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2021
Last Update Date: 05/08/2021
Certification Date: 05/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 CENTRAL AVE SW
ALBUQUERQUE NM
87102-2803
US

IV. Provider business mailing address

223 N GUADALUPE ST # 727
SANTA FE NM
87501-1868
US

V. Phone/Fax

Practice location:
  • Phone: 505-347-8136
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DELAINA MARTINEZ
Title or Position: OWNER
Credential:
Phone: 505-347-8136