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General NPI Number Information
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NPI Number | 1700495165
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Entity Type | Organization
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Legal Business Name | WELLSPRING OF LIFE ENTERPRISES LLC
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Dates
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Enumeration Date | 07/30/2020
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Last Update Date | 07/30/2020
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Provider Practice Location Address
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Address Line | 109 W BLAND ST
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City | ROSWELL
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State | NM
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Zip | 88203-5708
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Country | US
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Telephone | 575-420-1609
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 711
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City | ROSWELL
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State | NM
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Zip | 88202-0711
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Country | US
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Telephone | 575-420-1609
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. MARY MCMAHON
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Credential |
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Telephone | 575-420-1609
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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