Healthcare Provider Details

I. General information

NPI: 1932848785
Provider Name (Legal Business Name): KIDNEY WELLNESS CENTER LC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2022
Last Update Date: 05/31/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 S TELSHOR BLVD STE 101
LAS CRUCES NM
88011-4688
US

IV. Provider business mailing address

6825 BRIGHT VIEW RD
LAS CRUCES NM
88007-8935
US

V. Phone/Fax

Practice location:
  • Phone: 575-496-9501
  • Fax:
Mailing address:
  • Phone: 575-496-9501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. OSVALDO RENE DE LA VEGA
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 575-496-9501