Healthcare Provider Details

I. General information

NPI: 1336959667
Provider Name (Legal Business Name): BELLALUNA LIL LIGHT LLC/DBA MOUNTAIN GRIT WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2025
Last Update Date: 01/09/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3496 US HIGHWAY 82
MAYHILL NM
88339
US

IV. Provider business mailing address

PO BOX 22
MAYHILL NM
88339-0022
US

V. Phone/Fax

Practice location:
  • Phone: 575-687-4232
  • Fax:
Mailing address:
  • Phone: 575-491-2310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHARLENE E. ROGERS
Title or Position: OWNER/MANAGER/PROVIDER
Credential: CNP
Phone: 575-491-2310