Provider Demographics
NPI:1417489378
Name:PRIMARY WELLNESS TEAM CORPORATION
Entity Type:Organization
Organization Name:PRIMARY WELLNESS TEAM CORPORATION
Other - Org Name:REEF MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LIRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-202-3232
Mailing Address - Street 1:205 W BOUTZ RD
Mailing Address - Street 2:BLDG 1
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3262
Mailing Address - Country:US
Mailing Address - Phone:575-532-7000
Mailing Address - Fax:
Practice Address - Street 1:5805 MCNUTT RD
Practice Address - Street 2:STE D
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-8001
Practice Address - Country:US
Practice Address - Phone:575-265-1717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-30
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Single Specialty