Provider Demographics
NPI:1942883301
Name:WELLVANA NEW MEXICO LLC
Entity Type:Organization
Organization Name:WELLVANA NEW MEXICO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF STRATEGY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PLATEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-293-1372
Mailing Address - Street 1:40 BURTON HILLS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6291
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40 BURTON HILLS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37215-6291
Practice Address - Country:US
Practice Address - Phone:615-293-1372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLVANA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization