Healthcare Provider Details

I. General information

NPI: 1467083956
Provider Name (Legal Business Name): NEW MEXICO WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2020
Last Update Date: 02/03/2020
Certification Date: 02/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4111 BARBARA LOOP SE STE E1
RIO RANCHO NM
87124-1068
US

IV. Provider business mailing address

2737 BAYAS RD SE
RIO RANCHO NM
87124-2971
US

V. Phone/Fax

Practice location:
  • Phone: 505-715-9587
  • Fax: 505-792-7982
Mailing address:
  • Phone: 505-715-9587
  • Fax: 505-792-7982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: STEFANIE JULIANO
Title or Position: OWNER
Credential: LPCC
Phone: 505-715-9587