Provider Demographics
NPI:1043680028
Name:WHOLE BODY WELLNESS
Entity Type:Organization
Organization Name:WHOLE BODY WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:LMT,CMT
Authorized Official - Phone:505-660-9110
Mailing Address - Street 1:2 AVENIDA DE COMPADRES
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-8713
Mailing Address - Country:US
Mailing Address - Phone:505-660-9110
Mailing Address - Fax:
Practice Address - Street 1:460 SAINT MICHAELS DR
Practice Address - Street 2:SUITE 601
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7619
Practice Address - Country:US
Practice Address - Phone:505-660-9110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-02
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5906174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty