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General NPI Number Information
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NPI Number | 1336959667
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Entity Type | Organization
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Legal Business Name | BELLALUNA LIL LIGHT LLC/DBA MOUNTAIN GRIT WELLNESS LLC
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Dates
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Enumeration Date | 01/09/2025
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Last Update Date | 01/09/2025
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Provider Practice Location Address
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Address Line | 3496 US HIGHWAY 82
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City | MAYHILL
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State | NM
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Zip | 88339
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Country | US
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Telephone | 575-687-4232
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 22
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City | MAYHILL
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State | NM
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Zip | 88339-0022
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Country | US
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Telephone | 575-491-2310
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER/PROVIDER
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Name | SHARLENE E. ROGERS
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Credential | CNP
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Telephone | 575-491-2310
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 163WI0500X
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Taxonomy Name | Infusion Therapy Registered Nurse
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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