Healthcare Provider Details

I. General information

NPI: 1801702394
Provider Name (Legal Business Name): GOOD LIFE MED SPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W REINKEN AVE STE B
BELEN NM
87002-4257
US

IV. Provider business mailing address

315 W REINKEN AVE STE B
BELEN NM
87002-4257
US

V. Phone/Fax

Practice location:
  • Phone: 505-510-1621
  • Fax:
Mailing address:
  • Phone: 505-510-1621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. EDWARDJAMES GONZALES
Title or Position: DIRECTOR
Credential:
Phone: 505-510-1621