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General NPI Number Information
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NPI Number | 1689472904
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Entity Type | Organization
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Legal Business Name | AQUARIUS MEDICAL & WELLNESS CLINIC, LLC
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Dates
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Enumeration Date | 03/04/2025
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Last Update Date | 07/21/2025
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Provider Practice Location Address
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Address Line | 6 CALLE MEDICO STE 4
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City | SANTA FE
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State | NM
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Zip | 87505-4761
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Country | US
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Telephone | 813-484-2335
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Fax | 505-395-9251
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Provider Business Mailing Address
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Address Line | 6 CALLE MEDICO STE 4
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City | SANTA FE
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State | NM
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Zip | 87505-4761
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Country | US
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Telephone | 813-484-2335
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Fax | 505-395-9251
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Authorized Official
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Title or Position | OWNER
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Name | MS. ELIZABETH OLIS
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Credential | CNP
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Telephone | 813-484-2335
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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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 | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number |
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License Number State |
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