Healthcare Provider Details

I. General information

NPI: 1649796699
Provider Name (Legal Business Name): MEDICAL ASSISTED WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2017
Last Update Date: 10/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 WYATT DR STE 3
LAS CRUCES NM
88005-2960
US

IV. Provider business mailing address

4216 AURIGA CT
LAS CRUCES NM
88011-0940
US

V. Phone/Fax

Practice location:
  • Phone: 575-495-2000
  • Fax: 575-495-2000
Mailing address:
  • Phone: 423-388-5688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. JUSTIN MONTGOMERY
Title or Position: OWNER
Credential: NP
Phone: 423-388-5688