Healthcare Provider Details

I. General information

NPI: 1669866463
Provider Name (Legal Business Name): LIFECARE HEALTH & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2015
Last Update Date: 03/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 SIRINGO RD SUITE 201
SANTA FE NM
87505-5863
US

IV. Provider business mailing address

146 GLORY LN
GLORIETA NM
87535-7086
US

V. Phone/Fax

Practice location:
  • Phone: 505-989-3236
  • Fax: 505-989-5079
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP00935
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP00519
License Number StateNM

VIII. Authorized Official

Name: RENSO SELIM CAMPOS SANDOVAL
Title or Position: SINGLE MEMBER
Credential:
Phone: 505-603-8099