1689012569 NPI number — SOUTHWEST WELLNESS & LIFE ENHANCEMENT CENTER

Table of content: (NPI 1689012569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689012569 NPI number — SOUTHWEST WELLNESS & LIFE ENHANCEMENT CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST WELLNESS & LIFE ENHANCEMENT CENTER
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:
1689012569
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7 ENCINO PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81005-2948
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-561-9084
Provider Business Mailing Address Fax Number:
719-564-5605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
503 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 326
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81003-3130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-561-9084
Provider Business Practice Location Address Fax Number:
719-564-5605
Provider Enumeration Date:
06/12/2013

Additional Information

Authorized Official

Authorized Official Last Name:
ARMIJO
Authorized Official First Name:
ADELINE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
719-561-9084

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  989979 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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