Healthcare Provider Details

I. General information

NPI: 1861607400
Provider Name (Legal Business Name): BERNALILLO SPARTAN WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 02/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 SPARTAN ALY
BERNALILLO NM
87004-6298
US

IV. Provider business mailing address

P.O. BOX 927
LAS VEGAS NM
87701
US

V. Phone/Fax

Practice location:
  • Phone: 505-426-2262
  • Fax: 505-454-1473
Mailing address:
  • Phone: 505-426-2262
  • Fax: 505-454-1473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES ADRIAN ABREU
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 505-454-3523