Healthcare Provider Details

I. General information

NPI: 1417489378
Provider Name (Legal Business Name): PRIMARY WELLNESS TEAM CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 06/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5805 MCNUTT RD STE D
SANTA TERESA NM
88008-8001
US

IV. Provider business mailing address

205 W BOUTZ RD BLDG 1
LAS CRUCES NM
88005-3262
US

V. Phone/Fax

Practice location:
  • Phone: 575-265-1717
  • Fax:
Mailing address:
  • Phone: 575-532-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: CHRISTIAN LIRA
Title or Position: MANAGER
Credential:
Phone: 915-202-3232