MEDICARE: WELLNESS CLINICAL SERVICES INC.

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	251S00000X	Community/Behavioral Health Agency	0318	NM

General Provider Information

NPI Number	:	1871799858
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLNESS CLINICAL SERVICES INC.

Provider Business Mailing Address
First Line	:	721 BOND ST
Second Line	:
City	:	ESPANOLA
State	:	NM
Zip	:	87532-2729
Country	:	US
Telephone Number	:	505-753-5811
Fax Number	:	505-747-3210

Provider Business Practice Location Address
First Line	:	721 BOND ST
Second Line	:
City	:	ESPANOLA
State	:	NM
Zip	:	87532-2729
Country	:	US
Telephone Number	:	505-753-5811
Fax Number	:	505-747-3210

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN GEORGE LANG
Credential	:	PHD
Telephone Number	:	505-753-5811

Provider Enumeration Date	:	06/26/2007
Last Update Date	:	08/22/2020

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