Healthcare Provider Details

I. General information

NPI: 1285109561
Provider Name (Legal Business Name): WHOLE SELF RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2018
Last Update Date: 10/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 W PUEBLO DR
ESPANOLA NM
87532-2508
US

IV. Provider business mailing address

PO BOX 4621
SANTA FE NM
87502-4621
US

V. Phone/Fax

Practice location:
  • Phone: 506-747-3368
  • Fax: 505-367-0077
Mailing address:
  • Phone: 505-920-6020
  • Fax: 505-367-0077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KARTAR KHALSA
Title or Position: OWNER
Credential: DOM
Phone: 505-920-6020