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General NPI Number Information
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NPI Number | 1649796699
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Entity Type | Organization
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Legal Business Name | MEDICAL ASSISTED WELLNESS LLC
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Dates
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Enumeration Date | 08/21/2017
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Last Update Date | 10/13/2017
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Provider Practice Location Address
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Address Line | 121 WYATT DR STE 3
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City | LAS CRUCES
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State | NM
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Zip | 88005-2960
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Country | US
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Telephone | 575-495-2000
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Fax | 575-495-2000
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Provider Business Mailing Address
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Address Line | 4216 AURIGA CT
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City | LAS CRUCES
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State | NM
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Zip | 88011-0940
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Country | US
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Telephone | 423-388-5688
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. JUSTIN MONTGOMERY
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Credential | NP
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Telephone | 423-388-5688
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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