Healthcare Provider Details

I. General information

NPI: 1598067183
Provider Name (Legal Business Name): NEW SELF LOVE FOUNDATION . INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2010
Last Update Date: 12/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 PAWHUSKA DRIVE
TIMBERON NM
88350
US

IV. Provider business mailing address

P.O. BOX 166 123 PAWHUSKA DRIVE
TIMBERON NM
88350
US

V. Phone/Fax

Practice location:
  • Phone: 575-987-2719
  • Fax:
Mailing address:
  • Phone: 575-987-2719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number2962215
License Number StateNM

VIII. Authorized Official

Name: MS. MARGUERITA GASPARD
Title or Position: C.E.O.
Credential:
Phone: 575-987-2719