Provider Demographics
NPI:1255164976
Name:WILDFLOWER WELLNESS OF NEW MEXICO, LLC
Entity type:Organization
Organization Name:WILDFLOWER WELLNESS OF NEW MEXICO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEFINA
Authorized Official - Middle Name:BRIANNA
Authorized Official - Last Name:ISAACSON
Authorized Official - Suffix:
Authorized Official - Credentials:DOM
Authorized Official - Phone:505-228-7128
Mailing Address - Street 1:1336 WYOMING BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-5066
Mailing Address - Country:US
Mailing Address - Phone:505-228-7128
Mailing Address - Fax:
Practice Address - Street 1:1336 WYOMING BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-5066
Practice Address - Country:US
Practice Address - Phone:505-228-7128
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1710534037OtherNPPES
NM1952181893OtherNPPES