Provider Demographics
NPI:1437684727
Name:SACRED MOUNTAIN HEALTH AND WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:SACRED MOUNTAIN HEALTH AND WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-491-3031
Mailing Address - Street 1:275 N MAIN ST
Mailing Address - Street 2:STE 3
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1274
Mailing Address - Country:US
Mailing Address - Phone:575-491-3031
Mailing Address - Fax:
Practice Address - Street 1:275 N MAIN ST
Practice Address - Street 2:STE 3
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1274
Practice Address - Country:US
Practice Address - Phone:575-491-3031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health