Provider Demographics
NPI:1487035515
Name:SAN JUAN WELLNESS SERVICES INC
Entity Type:Organization
Organization Name:SAN JUAN WELLNESS SERVICES INC
Other - Org Name:FIT4EVER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CROTTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-564-7980
Mailing Address - Street 1:110 E APACHE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6902
Mailing Address - Country:US
Mailing Address - Phone:505-564-7980
Mailing Address - Fax:505-564-7956
Practice Address - Street 1:110 E APACHE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6902
Practice Address - Country:US
Practice Address - Phone:505-564-7980
Practice Address - Fax:505-564-7956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-15
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty