Healthcare Provider Details

I. General information

NPI: 1790650414
Provider Name (Legal Business Name): BLUE CEDAR WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2025
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 US HIGHWAY 491
GALLUP NM
87301-5340
US

IV. Provider business mailing address

915 US HIGHWAY 491
GALLUP NM
87301-5340
US

V. Phone/Fax

Practice location:
  • Phone: 505-870-8562
  • Fax:
Mailing address:
  • Phone: 505-870-8562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: ROBBIE WHITEHAIR
Title or Position: OWNER
Credential:
Phone: 505-870-8562