Healthcare Provider Details

I. General information

NPI: 1447963152
Provider Name (Legal Business Name): SELENITE HEALTH AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2022
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 RIDGECREST DR SE
RIO RANCHO NM
87124-5907
US

IV. Provider business mailing address

1199 MIRADOR LOOP NE
RIO RANCHO NM
87144-5324
US

V. Phone/Fax

Practice location:
  • Phone: 505-225-1975
  • Fax:
Mailing address:
  • Phone: 281-682-9067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: ABIGAIL BANMBUH
Title or Position: CEO
Credential: PMHNP
Phone: 505-225-1975