Provider Demographics
NPI:1245552330
Name:TOTAL HEALTH AND WELLNESS CENTER OF TAOS INC
Entity type:Organization
Organization Name:TOTAL HEALTH AND WELLNESS CENTER OF TAOS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-737-5810
Mailing Address - Street 1:5401 NDCBU
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6117
Mailing Address - Country:US
Mailing Address - Phone:575-737-5810
Mailing Address - Fax:575-737-5811
Practice Address - Street 1:622 PASEO DEL PUEBLO SUR STE B
Practice Address - Street 2:5401 NDCBU
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-5101
Practice Address - Country:US
Practice Address - Phone:575-737-5810
Practice Address - Fax:575-737-5811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-17
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3212040OtherNCPDP PROVIDER IDENTIFICATION NUMBER