Provider Demographics
NPI:1184499238
Name:INNER FLAME WELLNESS, LLC
Entity type:Organization
Organization Name:INNER FLAME WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:VIGIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-636-7117
Mailing Address - Street 1:111 CADENA ST
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:NM
Mailing Address - Zip Code:88048-9348
Mailing Address - Country:US
Mailing Address - Phone:575-636-7117
Mailing Address - Fax:
Practice Address - Street 1:525 S MELENDRES ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2805
Practice Address - Country:US
Practice Address - Phone:575-636-7117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-20
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM80081045Medicaid