Healthcare Provider Details

I. General information

NPI: 1043680028
Provider Name (Legal Business Name): WHOLE BODY WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2015
Last Update Date: 12/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 SAINT MICHAELS DR SUITE 601
SANTA FE NM
87505-7619
US

IV. Provider business mailing address

2 AVENIDA DE COMPADRES
SANTA FE NM
87508-8713
US

V. Phone/Fax

Practice location:
  • Phone: 505-660-9110
  • Fax:
Mailing address:
  • Phone: 505-660-9110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number5906
License Number StateNM

VIII. Authorized Official

Name: JENNIFER FOWLER
Title or Position: MEDICAL MASSAGE THERAPIST
Credential: LMT,CMT
Phone: 505-660-9110