Provider Demographics
NPI:1508482316
Name:WELLNESS AND AESTHETICS LLC
Entity Type:Organization
Organization Name:WELLNESS AND AESTHETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-288-1336
Mailing Address - Street 1:330 N CAMPO ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-3433
Mailing Address - Country:US
Mailing Address - Phone:575-288-1336
Mailing Address - Fax:323-334-1449
Practice Address - Street 1:330 N CAMPO ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3433
Practice Address - Country:US
Practice Address - Phone:575-525-3700
Practice Address - Fax:323-334-1449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-18
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM79858872Medicaid