Healthcare Provider Details

I. General information

NPI: 1629245543
Provider Name (Legal Business Name): WALSH WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 05/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 N PRINCE ST
CLOVIS NM
88101-9707
US

IV. Provider business mailing address

4101 N PRINCE ST
CLOVIS NM
88101-9707
US

V. Phone/Fax

Practice location:
  • Phone: 575-935-3488
  • Fax:
Mailing address:
  • Phone: 575-935-3488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR28624
License Number StateNM

VIII. Authorized Official

Name: MR. RUSSELL DARIN SPICHER
Title or Position: BILLING CLERK
Credential:
Phone: 806-771-1166