=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518568195
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELL LIFE ABQ, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2020
-----------------------------------------------------
Last Update Date | 11/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8400 OSUNA RD NE STE 5C
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87111-2072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-585-2345
-----------------------------------------------------
Fax | 505-800-5030
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8400 OSUNA RD NE STE 5C
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87111-2072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-585-2345
-----------------------------------------------------
Fax | 505-800-5030
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | SASHA SANCHEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-585-2345
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------