Healthcare Provider Details

I. General information

NPI: 1780067876
Provider Name (Legal Business Name): EASTERN HILLS HEALTH & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 MCLEOD RD NE SUITE C
ALBUQUERQUE NM
87109-2454
US

IV. Provider business mailing address

5800 MCLEOD RD NE SUITE C
ALBUQUERQUE NM
87109-2454
US

V. Phone/Fax

Practice location:
  • Phone: 505-401-1188
  • Fax: 505-884-4995
Mailing address:
  • Phone: 505-401-1188
  • Fax: 505-884-4995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number1045
License Number StateNM

VIII. Authorized Official

Name: NANCY CARR RANDALL
Title or Position: PRESIDENT
Credential: DOM
Phone: 505-401-1188