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General NPI Number Information
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NPI Number | 1811823800
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Entity Type | Organization
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Legal Business Name | DIVINE WELLNESS AND PRIMARY CARE LLC
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Dates
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Enumeration Date | 06/18/2026
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Last Update Date | 06/18/2026
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Provider Practice Location Address
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Address Line | 2235 MAIN ST SE STE C
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City | LOS LUNAS
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State | NM
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Zip | 87031-8889
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Country | US
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Telephone | 505-720-5212
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Fax |
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Provider Business Mailing Address
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Address Line | 2235 MAIN ST SE STE C
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City | LOS LUNAS
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State | NM
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Zip | 87031-8889
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/NP
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Name | LARISSA BALDONADO
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Credential | NP
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Telephone | 505-720-5212
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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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