Healthcare Provider Details

I. General information

NPI: 1427996347
Provider Name (Legal Business Name): MIRAGE WELLNESS CENTER & MEDSPA LIMITED LIABILITY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 BARBARA LOOP SE STE A
RIO RANCHO NM
87124-1088
US

IV. Provider business mailing address

1400 BARBARA LOOP SE STE A
RIO RANCHO NM
87124-1088
US

V. Phone/Fax

Practice location:
  • Phone: 505-420-3737
  • Fax: 505-420-3738
Mailing address:
  • Phone: 505-420-3737
  • Fax: 505-420-3738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: ELENA MARTINEZ
Title or Position: PRACTICE MANAGER
Credential: PRACTICE MANAGER
Phone: 505-420-3737