Provider Demographics
NPI:1689012569
Name:SOUTHWEST WELLNESS & LIFE ENHANCEMENT CENTER
Entity Type:Organization
Organization Name:SOUTHWEST WELLNESS & LIFE ENHANCEMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ADELINE
Authorized Official - Middle Name:D
Authorized Official - Last Name:ARMIJO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:719-561-9084
Mailing Address - Street 1:7 ENCINO PL
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-2948
Mailing Address - Country:US
Mailing Address - Phone:719-561-9084
Mailing Address - Fax:719-564-5605
Practice Address - Street 1:503 N MAIN ST
Practice Address - Street 2:SUITE 326
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3130
Practice Address - Country:US
Practice Address - Phone:719-561-9084
Practice Address - Fax:719-564-5605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9899791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty