Provider Demographics
NPI:1669866463
Name:LIFECARE HEALTH & WELLNESS
Entity Type:Organization
Organization Name:LIFECARE HEALTH & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SINGLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RENSO
Authorized Official - Middle Name:SELIM
Authorized Official - Last Name:CAMPOS SANDOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-603-8099
Mailing Address - Street 1:146 GLORY LN
Mailing Address - Street 2:
Mailing Address - City:GLORIETA
Mailing Address - State:NM
Mailing Address - Zip Code:87535-7086
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 SIRINGO RD
Practice Address - Street 2:SUITE 201
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5863
Practice Address - Country:US
Practice Address - Phone:505-989-3236
Practice Address - Fax:505-989-5079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-19
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP00519363LF0000X
NMCNP00935363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty