MEDICARE: MIRAGE WELLNESS CENTER & MEDSPA LIMITED LIABILITY COMPANY

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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1427996347
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRAGE WELLNESS CENTER & MEDSPA LIMITED LIABILITY COMPANY

Provider Business Mailing Address
First Line	:	1400 BARBARA LOOP SE STE A
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87124-1088
Country	:	US
Telephone Number	:	505-420-3737
Fax Number	:	505-420-3738

Provider Business Practice Location Address
First Line	:	1400 BARBARA LOOP SE STE A
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87124-1088
Country	:	US
Telephone Number	:	505-420-3737
Fax Number	:	505-420-3738

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	ELENA MARTINEZ
Credential	:	PRACTICE MANAGER
Telephone Number	:	505-420-3737

Provider Enumeration Date	:	03/23/2026
Last Update Date	:	03/23/2026

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