Healthcare Provider Details

I. General information

NPI: 1972609188
Provider Name (Legal Business Name): CHILDREN'S WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 12/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 MISSOURI AVE STE 9-10
LAS CRUCES NM
88011-5075
US

IV. Provider business mailing address

2801 MISSOURI AVE STE 9-10
LAS CRUCES NM
88011-5075
US

V. Phone/Fax

Practice location:
  • Phone: 575-524-4100
  • Fax: 575-532-9221
Mailing address:
  • Phone: 575-532-9077
  • Fax: 575-532-9221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY HERNDON
Title or Position: OWNER
Credential:
Phone: 505-524-4100