MEDICARE: CASA DE MI ALMA WELLNESS CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	C-07976	NM

General Provider Information

NPI Number	:	1366807323
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CASA DE MI ALMA WELLNESS CENTER, LLC

Provider Business Mailing Address
First Line	:	920 N ALAMEDA BLVD
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-2291
Country	:	US
Telephone Number	:	575-993-8143
Fax Number	:

Provider Business Practice Location Address
First Line	:	920 N ALAMEDA BLVD
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-2291
Country	:	US
Telephone Number	:	575-993-8143
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. ALMA DE LA O
Credential	:	LISW
Telephone Number	:	575-993-8143

Provider Enumeration Date	:	12/17/2015
Last Update Date	:	12/17/2015

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