Healthcare Provider Details

I. General information

NPI: 1396503801
Provider Name (Legal Business Name): SENIOR WELLNESS HOMECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2024
Last Update Date: 03/08/2024
Certification Date: 03/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 21ST ST SE UNIT B1
RIO RANCHO NM
87124-4030
US

IV. Provider business mailing address

1380 RIO RANCHO BLVD SE STE 485
RIO RANCHO NM
87124-1006
US

V. Phone/Fax

Practice location:
  • Phone: 505-359-3586
  • Fax:
Mailing address:
  • Phone: 928-255-3684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. KATRINA MAYE EUGENIO DIVIDINA
Title or Position: OWNER
Credential: RN
Phone: 928-255-3684