Healthcare Provider Details

I. General information

NPI: 1538761093
Provider Name (Legal Business Name): NEW MEXICO WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 05/20/2022
Certification Date: 05/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4210 MEADOWLARK LN SE
RIO RANCHO NM
87124-1021
US

IV. Provider business mailing address

4210 MEADOWLARK LN SE
RIO RANCHO NM
87124-1021
US

V. Phone/Fax

Practice location:
  • Phone: 505-362-0758
  • Fax:
Mailing address:
  • Phone: 505-362-0758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MELONIE BACOCCINI
Title or Position: OWNER
Credential:
Phone: 505-362-0758