Healthcare Provider Details

I. General information

NPI: 1811601537
Provider Name (Legal Business Name): BODY POTIONS EMPORIUM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 01/09/2023
Certification Date: 01/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 WYOMING BLVD NE STE 110
ALBUQUERQUE NM
87111-3286
US

IV. Provider business mailing address

3620 WYOMING BLVD NE STE 110
ALBUQUERQUE NM
87111-3286
US

V. Phone/Fax

Practice location:
  • Phone: 505-910-4410
  • Fax:
Mailing address:
  • Phone: 505-910-4410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. JAVIN LAEBEIN ATREIDES
Title or Position: FOUNDER CEO AND MASSAGE THERAPIST
Credential: LMT 8032
Phone: 505-688-1377