1316325061 NPI number — SERENITY WELLNESS CENTER OF SANTA FE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316325061 NPI number — SERENITY WELLNESS CENTER OF SANTA FE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERENITY WELLNESS CENTER OF SANTA FE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316325061
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 CORDOVA PLACE #411
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA FE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-690-3134
Provider Business Mailing Address Fax Number:
505-216-2616

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
343 E PALACE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-690-3134
Provider Business Practice Location Address Fax Number:
505-216-2616
Provider Enumeration Date:
05/14/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SHELBOURN
Authorized Official First Name:
ALISHA
Authorized Official Middle Name:
NICOLE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
505-690-3134

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  0094521 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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