Healthcare Provider Details

I. General information

NPI: 1962127878
Provider Name (Legal Business Name): MARIPOSA TRANSFORMATION WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2022
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 EUBANK BLVD NE SUITE D205
ALBUQUERQUE NM
87111-2565
US

IV. Provider business mailing address

4550 EUBANK BLVD NE SUITE D205
ALBUQUERQUE NM
87111
US

V. Phone/Fax

Practice location:
  • Phone: 505-234-6432
  • Fax:
Mailing address:
  • Phone: 505-234-6432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MS. MICHELLE RENEE LUCERO
Title or Position: PA-C / OWNER
Credential: PA-C
Phone: 505-234-6432