Healthcare Provider Details

I. General information

NPI: 1841801123
Provider Name (Legal Business Name): SUNSHINE WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2020
Last Update Date: 03/18/2022
Certification Date: 03/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W BROADWAY
MOUNTAINAIR NM
87036-8703
US

IV. Provider business mailing address

PO BOX 31
MOUNTAINAIR NM
87036-0031
US

V. Phone/Fax

Practice location:
  • Phone: 505-847-2995
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER SMITH FREER
Title or Position: OWNER
Credential: LCSW
Phone: 505-847-2320