Healthcare Provider Details

I. General information

NPI: 1811823800
Provider Name (Legal Business Name): DIVINE WELLNESS AND PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 MAIN ST SE STE C
LOS LUNAS NM
87031-8889
US

IV. Provider business mailing address

2235 MAIN ST SE STE C
LOS LUNAS NM
87031-8889
US

V. Phone/Fax

Practice location:
  • Phone: 505-720-5212
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LARISSA BALDONADO
Title or Position: OWNER/NP
Credential: NP
Phone: 505-720-5212